Method to inhibit ischemia and reperfusion injury

ABSTRACT

Methods of treating or inhibiting ischemia and reperfusion injury are provided.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation under 35 U.S.C. § 111(a) ofInternational Application No. PCT/US2003/021536 filed on Jul. 9, 2003and published in English as WO 2004/004702 A2 on Jan. 15, 2004, whichclaims the benefit under 35 U.S.C. § 119(e) of the filing date of U.S.provisional application Ser. No. 60/394,642, filed on Jul. 9, 2002, thedisclosures of which applications and publication are incorporated byreference herein.

STATEMENT OF GOVERNMENT RIGHTS

The invention was made, at least in part, with a grant from theGovernment of the United States of America (grants HL61518 and HL60590from the National Institutes of Health). The Government may have certainrights to the invention.

BACKGROUND OF THE INVENTION

Ischemic heart disease is a leading cause of death in North America andis predicted to become more prevalent as the population ages (Scroggins,2001). Ischemia and reperfusion lead to myocardial injury through avariety of mechanisms. For example, ischemia and reperfusion profoundlyaffect mitochondria, and preservation of their integrity and function iscritical to salvage (Borutaite et al., 1995; DiLisa et al., 1998; Kay etal., 1997; Ferrari et al., 1996; Kobara et al., 1996). Oxidativephosphorylation is transiently increased after reperfusion but thendiminishes; pyridine nucleotides are lost from the mitochondria, andrespiration through complex I is impaired; superoxide production isincreased, possibly through retrograde electron flow through complex I;the permeability transition pore opens, associated with loss of calciumhomeostasis; and cytochrome c is released (Borutaite et al., 1995; Duanet al., 1989; DiLisa et al., 1998; Piper et al., 1985; Becker et al.,1999; Halestrap et al., 1998). However, it is not clear whether thesemitochondrial alterations are initiated by an intrinsic response to thelow oxygen tension of ischemia or arise in part due to changes in thecytosol. Cytosolic alterations are known to include acidosis, increasedinorganic phosphate, elevated calcium, and a rise in long-chain acylcoenzyme A.

In addition, a variety of signal transduction pathways, including thatof MAP kinases, particularly c-Jun NH₂-terminal kinase (JNK), and p38,are activated during myocardial ischemia and reperfusion. Previously itwas shown that JNK translocates from cytosol to mitochondria in responseto ischemia/reperfusion, and that in a model of metabolic inhibition inadult rabbit cardiomyocytes, inhibition of JNK is protective (He et al.,1999).

Ischemic preconditioning confers myocardial protection through a briefperiod of ischemia and reperfusion preceding the more sustainedischemia/reperfusion insult (Murry et al., 1986). Preconditioning ischaracterized by earlier recovery of mitochondrial function with moreefficient resynthesis of ATP. Thus, it is clear from these diversestudies that ischemia and reperfusion activate cytosolic signals thattarget the mitochondria to modulate their response during ischemia andreperfusion, and furthermore, that preconditioning also involvessignaling from cytosol to mitochondria.

Current therapies for ischemic heart disease are directed at therestoration of blood flow to the ischemic region. However, duringreperfusion the heart undergoes further damage due in large part to thegeneration of reactive oxygen species (ROS), e.g., superoxide anion(Singh et al., 1995; Flaherty et al., 1988). Elevated ROS can bedetected within minutes after the reintroduction of oxygen to ischemictissues (Bolli et al., 1995). ROS have been shown to be key mediators ofcellular and myocardial injury, with free radical scavengers attenuatingthe associated injury (Cesselli et al., 2001). Low levels of superoxideplay a role in signaling pathways possibly contributing topreconditioning (Sun et al., 1996) and the development of hypertrophy(Ito et al., 1995). However, higher levels are detrimental, causinglipid peroxidation and apoptosis (Siwik et al., 1999; Halmosi et al.,2001). There are no current therapies for reperfusion injury.

Thus, what is needed is a method to inhibit ischemia and/or reperfusioninjury.

SUMMARY OF THE INVENTION

The invention provides a method to inhibit, treat or prevent injuryassociated with ischemia and/or reperfusion in a mammal, e.g., a human.Ischemia and/or reperfusion injury are associated with myocardialischemia (resulting from, for example, acute myocardial infarction,elective angioplasty, coronary artery bypass graft, surgery involvingcardiac bypass or cardiac transplantation), cerebral ischemia (resultingfrom, for example, stroke, head trauma or drowning), intestinalischemia, renal ischemia or tissue ischemia (resulting from sepsis,cardiac arrest, drowning or shock).

The method involves administering to a mammal having or at risk ofinjury associated with ischemia and/or reperfusion an effective amountof one or more agents. These agents include but are not limited toH₂-receptor antagonists; H⁺/K⁺ ATPase inhibitors; antimicrobials;antifugals, e.g., azoles, central nervous system (CNS)-active agentsincluding tricyclic antidepressants, serotonin reuptake inhibitorantidepressants, phenothiazine antipsychotics, and benzodiazepinesanxiolytics; nonsteroidal anti-inflammatory drugs (NSAIDs); metyrapone;7-ethoxyresorufin; HMG-CoA synthase inhibitors; sartans, and calciumchannel blockers; preferably the agent inhibits the amount or activityof one or more cytochrome P450 (CYP450 or CYP) enzymes. In oneembodiment, the agent is a H₂-receptor antagonist, e.g., cimetidine,ranitidine or ebrotidine. In one embodiment, the agent is a H+/K+-ATPaseinhibitor, e.g., omeprazole. In one embodiment, the agent is anantimicrobial or an antifungal, for instance, chloramphenicol,ketoconazole, sulfaphenazole, clotrimazole or miconazole. In oneembodiment, the agent is a tricyclic antidepressant, e.g., clomipramine,amitriptyline or desipramine. In one embodiment, the agent is aserotonin reuptake inhibitor, for instance, fluoxetine, sertraline orparoxetine. In another embodiment, the agent is a phenothiazine, e.g.,chlorpromazine. In one embodiment, the agent is a benzodiazepine, e.g.,flurazepam. In another embodiment, the agent is a nonsteroidalanti-inflammatory agent, e.g., diclofenac, flufenamine, fenoprofen,flubiprofen or ketaprofen. In another embodiment, the agent is a calciumchannel blocker. Exemplary preferred agents include but are not limitedto the H₂-receptor antagonists cimetidine, ranitidine, and ebrotidine;the H⁺/K⁺ ATPase inhibitor omeprazole; antimicrobials and antifungalssuch as chloramphenicol, econazole, ketoconazole, sulfaphenazole,trimethoprim, sulfamethoxazole, clotrimazole, and miconazole; CNS-activeagents including tricyclic antidepressants such as clomipramine,amitriptyline, and desipramine, serotonin reuptake inhibitorantidepressants such as fluoxetine, sertraline, and paroxetine,phenothiazine antipsychotics such as chlorpromazine; benzodiazepinesanxiolytics such as flurazepam and medazapam; NSAIDs such as diclofenac,flufenamine, fenoprofen, flurbiprofen, and ketoprofen; metyrapone;7-ethoxyresorufin; HMG-CoA synthase inhibitors such as the statins; andcalcium channel blockers such as diltiazem, verapamil, lercanidipine,nifedipine, nisoldipine, nicardipine, isradipine, nitrendipine,felodipine, and amlodipine, agents which inhibit one or more cytochromeP450 enzymes. Another effective agent may be the antiarrhythmicamiodarone. Additional agents useful to treat the indications orconditions described herein are flavonoids such as resveratrol and otherrelated compounds present in red wine, grape seed extracts, green tea,and other dietary and herbal sources of flavonoids. The administrationof the one or more agents may be prior to ischemia, after the onset ofischemia, after the onset of reperfusion, or any combination thereof. Inone embodiment, the one or more agents may be administeredintravenously. In one embodiment, the one or more agents may be orallyadministered. In one embodiment, the one or more agents are administeredvia a catheter, for instance, an angioplasty catheter, to a coronaryartery. In one embodiment, the one or more agents are administered via acatheter which comprises a drug delivery balloon.

It is also envisioned that agents other than those described above maybe employed in the methods of the invention, for instance, alone or inaddition to the agents described above, agents including, but notlimited to, agents that inhibit mitochondrial superoxide production,e.g., complex I inhibitors such as idebenone, rotenone,p-hydroxy-mercuribenzoate, rolliniastatin-2, capsaicin and amytal;complex III inhibitors, e.g., myxothiazol, antimycin A and mucidin(strobilurin A); and agents that inhibit superoxide production at othersites, for instance, xanthine oxidase inhibitors (e.g., allopurinol),and NAD(P)H oxidase inhibitors (e.g., apocynin and diphenyleneiodonium).

As described herein, pretreatment of hearts with chloramphenicol, aninhibitor of cytochrome P450, prior to ischemia and reperfusion,significantly reduced infarct size (by about 90%). Further,chloramphenicol administered after the ischemic insult reduced the sizeof the infarct by about 60 to about 80%. This was surprising as mostagents that are cardioprotective when administered before ischemia, arenot necessarily cardioprotective when administered after the onset ofischemia. Chloramphenicol also inhibits cytochrome P450 enzymes. Asfurther described herein, cimetidine and sulfaphenazole, both of whichinhibit cytochrome P450 enzymes but not protein synthesis, were shown toprevent or reduce reperfusion injury and O₂*⁻ generation in the heart.Interestingly, while weak inhibition of more than one isozyme may occurat the concentrations of inhibitors that were tested, the cytochromeP450 2C family is the only family of P450 isozymes that is known to beinhibited by chloramphenicol, sulfaphenazole, and cimetidine. Moreover,superoxide production, which more than doubles after ischemia andreperfusion, was reduced by 75% by drug treatment. These compounds canalso enhance coronary blood flow after ischemia, e.g., by improving thevasodilatory effects of nitric oxide owing to diminished superoxideproduction, and enhance cardiac contractility afterischemia/reperfusion, e.g., by preventing the production of thecardiotoxic cytochrome P450 metabolite 14,15-epoxyeicosatrienoic acid(14,15-EET).

Thus, agents which inhibit one or more cytochrome P450 enzymes, forinstance, one or more members of the cytochrome P450 1A family, e.g.,1A1, one or more members of the cytochrome P450 1 B family, e.g., 1 B 1,one or more members of the cytochrome P450 2B family, e.g., 2B6 or 2B7,one or more members of the cytochrome P450 2C family, e.g., 2C8-19, oneor more members of the cytochrome P450 2D family, e.g., 2D6, one or moremembers of the cytochrome P450 2E family, e.g., 2E1, one or more membersof the cytochrome P450 2F family, e.g., 2F2, one or more members of thecytochrome P450 4A family, e.g., 4A10, one or more members of thecytochrome P450 2J family, e.g., 2J2, or one or more members of thecytochrome P450 4B family, e.g., 4B 1, can limit the production ofcardiotoxic agents including singlet oxygen, superoxide and eicosanoids,are cardioprotective and so abrogate injury due to ischemia andreperfusion that is associated with a variety of indications orconditions, for instance, myocardial infarction. Moreover, since theseagents can be administered with the onset of reperfusion, they areclinically applicable as an adjuvant to angioplasty, e.g., whichincludes stent placement, or thrombolytic therapy.

Accordingly, the agents described herein including inhibitors of one ormore cytochrome P450 enzymes have value for the treatment of thefollowing exemplary indications or conditions: acute myocardialinfarction; angioplasty; coronary artery bypass graft surgery; surgeryinvolving cardiac bypass; ischemia/reperfusion injury in any organ;stroke (cerebrovascular accident); organ transplantation; septic ortraumatic shock, as well as other pathologic processes, includingatherosclerosis, hypertension, cocaine-induced heart disease,smoking-induced heart disease, heart failure, and pulmonaryhypertension.

In one embodiment of the invention, a method to treat or inhibitischemia and/or reperfusion injury is provided. The method involvesadministering to a mammal, for instance, a human, having or at risk ofischemia and/or reperfusion injury an effective amount of one or moreagents including H₂-receptor antagonists; H⁺/K⁺ ATPase inhibitors;antimicrobials; antifungals; central nervous system (CNS)-active agentsincluding tricyclic antidepressants, serotonin reuptake inhibitorantidepressants; phenothiazine antipsychotics; benzodiazepinesanxiolytics; nonsteroidal anti-inflammatory drugs (NSAIDs); metyrapone;7-ethoxyresorufm; HMG-CoA synthase inhibitors; sartans; or calciumchannel blockers inhibitors, which agent(s) preferably inhibit one ormore cytochrome P450 enzymes. The administration of the one or moreagents may be prior to ischemia, after the onset of ischemia, after theonset of reperfusion, or any combination thereof.

In one aspect of the invention, the method involves administering to amammal, such as a human, prior to the onset of ischemia, an amount ofone or more agents including H₂-receptor antagonists; H⁺/K⁺ ATPaseinhibitors; antimicrobials; antifugals; central nervous system(CNS)-active agents including tricyclic antidepressants, serotoninreuptake inhibitor antidepressants; phenothiazine antipsychotics;benzodiazepines anxiolytics; nonsteroidal anti-inflammatory drugs(NSAIDs); metyrapone; 7-ethoxyresorufm; HMG-CoA synthase inhibitors;sartans; or calcium channel blockers inhibitors, which agent(s)preferably inhibit one or more cytochrome P450 enzymes, effective totreat or inhibit ischemia and/or reperfusion injury, e.g., due to avascular interventional procedure. The administration may begin prior toischemia and/or reperfusion and may continue after the onset of ischemiaand/or reperfusion. Agents including inhibitors of cytochrome P450enzymes may thus be employed as a prophylactic treatment beforeangioplasty, coronary artery bypass graft or other vascularinterventional procedures, or as a pretreatment for donor organs, e.g.,a heart, lung, liver or kidney, in the transplant setting, e.g., beforeorgan harvest and optionally administered to the organ recipient, aswell as to protect the heart against ischemic injury such as occurs inthe setting of acute angina.

Accordingly, the invention provides a method to inhibit ischemia andreperfusion injury in a mammalian donor organ. The method involvescontacting the donor organ with an effective amount one or more agentsselected from the group consisting of a H₂-receptor antagonist, aH+/K+-ATPase inhibitor, an antimicrobial, an antifungal, a tricyclicantidepressant, a serotonin reuptake inhibitor, a phenothiazine, abenzodiazepine, a calcium channel blocker, and a nonsteroidalanti-inflammatory drug, wherein the one or more agents inhibit one ormore cytochrome P450 enzymes. In one embodiment, the agent is aH₂-receptor antagonist, e.g., cimetidine, ranitidine or ebrotidine. Inone embodiment, the agent is a H+/K+-ATPase inhibitor, e.g., omeprazole.In one embodiment, the agent is an antimicrobial or an antifungal, forinstance, chloramphenicol, ketoconazole, sulfaphenazole, clotrimazole ormiconazole. In one embodiment, the agent is a tricyclic antidepressant,e.g., clomipramine, amitriptyline or desipramine. In one embodiment, theagent is a serotonin reuptake inhibitor, for instance, fluoxetine,sertraine or paroxetine. In another embodiment, the agent is aphenothiazine, e.g., chlorpromazine. In one embodiment, the agent is abenzodiazepine, e.g., flurazepam. In another embodiment, the agent is anonsteroidal anti-inflammatory agent, e.g., diclofenac, flufenamine,fenoprofen, flubiprofen or ketaprofen. In another embodiment, the agentis a calcium channel blocker.

In another embodiment, the invention provides a method to inhibitreperfusion injury by administering to a mammal, after the onset ofischemia, an effective amount of one or more of the agents describedherein, e.g., an agent that inhibits one or more cytochrome P450enzymes.

The agents of the invention may be administered by any route or means,including, but not limited to, by administration of agent intravenously(e.g., before a scheduled procedure), by catheter to an organ at risk ofischemic or reperfusion injury (e.g., intracoronary delivery via anangioplasty catheter with a drug delivery balloon), or orally, or incombination with thrombolytic agents (i.v.).

The present invention also provides a composition and kit which includesa substantially pure preparation of one or more of the agents describedherein as useful to inhibit, prevent or treat ischemic or reperfusioninjury. The composition is composed of an agent in an amount effectiveto selectively inhibit one or more cytochrome P450 enzymes and a carriersuch as a pharmaceutically acceptable carrier. The composition or kitoptionally includes one or more other therapeutic agents, e.g., an agentof the invention and a thrombolytic. The kit may be composed of two ormore containing means, for example, two vials each with a differentagent, or a single containing means with one or more of the agentsdescribed herein.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1. Experimental protocol for treatment of isolated hearts (A) orrabbits (B) during ischemia and reperfusion or reperfusion only.

FIG. 2. Reduced infarcts in chloramphenicol-, cimetidine- andsulfaphenazole-treated hearts after ischemia/reperfusion (I/R). Adultrat hearts were perfused in Langendorff mode for 20 minutes, thensubjected to 30 minutes no-flow ischemia followed by a 2 hourreperfusion. Chloramphenicol (CAP), gentamicin, cimetidine, orsulfaphenazole was added for the entire procedure (Full) or immediatelyafter ischemia for reperfusion (CAP-After). (A) After 2 hours ofreperfusion, hearts were frozen and assessed for infarct size using TTC.Coronary effluent was collected for 15 minutes immediately before andafter ischemia and assessed for CK release. Error bars denote SEM. *indicates p<0.01, and ** indicates P<0.001 (comparison to I/R). (B)Representative heart sections stained with TTC for each treatment.

FIG. 3. Chloramphenicol significantly reduces infarct size andsuppresses post-ischemic hypotension following circumflex coronaryartery occlusion in rabbits. Rabbits were injected with or without CAP(20 mg/kg) 30 minutes before the induction of 30 minutes of ischemia(coronary occlusion) followed by 4 hours reperfusion. (A) At 4 hours,hearts were removed, immediately frozen and blindly assessed for infarctsize. The decrease in left ventricular pressure from baseline wasassessed after ischemia. The error bars represent the mean and standarderror (n=6). The asterisk represents a p value<0.05. (B) Rat hearts wereperfused in Langendorff mode with or without CAP (100 μg/ml) for 15minutes and then subjected to 20 minutes ischemia and 15 minutesreperfusion with the same buffer. Superoxide levels were assessed bymeasuring DHE conversion to ethidium. The asterisk represents a pvalue<0.05. Error bars represent the standard error forischemia/reperfusion (n=5), ischemia/reperfusion+CAP (100 μg/ml) (n=4).

FIG. 4. Effect of chloramphenical infusion on mitochondria and CYPactivity. (A) Mitochondria isolated from hearts perfused with or withoutchloramphenicol were assessed for expression levels of mitochondrialgenome-encoded proteins cytochrome oxidase subunit 1 (CO-1) and Complex1 subunit 3 (ND3). (B) Mitochondrial respiration was measured bypolarography. State 3 and State 4 respiration are shown forpalmitoylcarnitine (Complex 1 substrate), succinate (Complex IIsubstrate), and TMPD/ascorbate (Complex IV substrate). Error barsrepresent standard deviation. (C) Cardiac microsomes were prepared fromhearts perfused with or without chloramphenicol, and CYP activity wasmeasured as the NADPH-dependent demethylation reaction of AMMC.

FIG. 5. Effect of sulfaphenazole on AMMC demethylase activity. (A) Therate of AHMC product formation was assessed and the IC₅₀ value wascalculated. (B) AHMC product formation was measured over 2 hours inbaulovirus-infected CYP2D2-specific supersomes in the presence orabsence of sulfaphenazole (50 μM) (SUL).

DETAILED DESCRIPTION OF THE INVENTION

I. Definitions

The term “an effective amount” of an agent is the amount sufficient totreat, inhibit, or prevent ischemia and/or reperfusion injury associatedwith indications and conditions including, but not limited to,myocardial infarction, stroke, septic shock, traumatic shock, andassociated with vascular interventional procedures includingangioplasty, any surgery involving cardiac bypass, cardiac artery bypassgraft surgery and organ transplantation. A preferred effective amount isthat which selectively inhibits one or more cytochrome P450 enzymes. Forinstance, in vitro, 10 μM sulfaphenazole is selective for inhibition ofcytochrome P450 2C. Exemplary amounts for exemplary agents for selectiveinhibition in vivo are 50 mg/kg/day chloramphenicol; 800 to 1600 mg/day,optionally in divided doses, or 50 mg/hr (infusion) for cimetidine; 80to 200 mg/day (divided doses) or 160 mg/hr (infusion) for trimethoprim;800 to 1600 mg/day (divided doses) for sulfamethoxazole; and 750 mgevery four hours (15 mg/kg =single dose) for methyrpone. Methods toidentify amounts which selectively inhibit cytochrome P450 enzymes areknown to the art (see, e.g., Masimirembwa et al., 2001; Kelly et al.,2000; Masubuchi et al., 1998). An effective amount of an agent useful inthe methods of the invention can vary according to factors such as theagent selected, and the age, sex, health and weight of the mammal, andcan be determined by methods within the skill of the art.

By “pharmaceutically acceptable” it is meant a carrier, diluent,excipient, and/or salt that is compatible with the other ingredients ofthe formulation, and not deleterious to the recipient thereof.

“Pharmaceutically acceptable salts” are salts of compounds employed inthis invention which are sufficiently acidic or basic to form non-toxicacid or base salts, e.g., prepared by reacting a free acid with asuitable organic or inorganic base. Examples of salt forms may include,but are not limited to, acetate, benzenesulfonate, benzoate,bicarbonate, bisulfate, bitartrate, borate, bromide, calcium, calciumedetate, camsylate, carbonate, chloride, clavulanate, citrate,dihydrochloride, edetate, edisylate, estolate, esylate, fumarate,gluceptate, gluconate, glutamate, glycollylarsanilate, hexylresorcinate,hydrabamine, hydrobromide, hydrochloride, hydroxynapthoate, iodide,isothionate, lactate, lactobionate, laurate, malate, maleate, mandelate,mesylate, methylbromide, methylnitrate, methylsulfate, mucate,napsylate, nitrate, oleate, oxalate, pamaote, palmitate, panthothenate,phosphate/diphosphate, polygalacturonate, potassium, salicylate, sodium,stearate, subacetate, succinate, tannate, tartrate, teoclate, tosylate,triethiodide, and valerate, and salts derived from inorganic basesincluding aluminum, ammonium, calcium, copper, ferric, ferrous, lithium,magnesium, manganic salts, manganous, potassium, sodium, zinc, and thelike. Salts derived from organic non-toxic bases include salts ofprimary, secondary, and tertiary amines, substituted amines includingnaturally occurring substituted amines, cyclic amines, and basic ionexchange resins, such as arginine, betaine, caffeine, choline,N,N-dibenzylethylenediamine, diethylamine, 2-diethylaminoethanol,2-dimethylaminoethanol, ethanolamine, ethylenediamine,N-ethylmorpholine, N-ethylpiperidine, glucamine, glucosamine, histidine,hydrabamine, isopropylamine, lysine, methylglucamine, morpholine,piperazine, piperidine, polyamine resins, procaine, purines,theobromine, triethylamine, trimethylamine, tripropylamine,tromethamine, and the like.

Examples of pharmaceutically acceptable salts are organic acid additionsalts formed with acids which form a physiological acceptable anion, forexample, tosylate, methanesulfonate, acetate, citrate, malonate,tartarate, succinate, benzoate, ascorbate, α-ketoglutarate, andα-glycerophosphate. Suitable inorganic salts may also be formed,including hydrochloride, sulfate, nitrate, bicarbonate, and carbonatesalts. Salts derived from carboxylic acids include esters thereof,preferably alkyl esters.

Pharmaceutically acceptable salts may be obtained using standardprocedures well known in the art, for example, by reacting asufficiently basic compound such as an amine with a suitable acidaffording a physiological acceptable anion.

As used herein, “substantially pure” means an object species is thepredominant species present (i.e., on a molar basis it is more abundantthan any other individual species in the composition), and preferably asubstantially purified fraction is a composition wherein the objectspecies comprises at least about 50 percent (on a molar basis) of allmacromolecular species present. Generally, a substantially purecomposition will comprise more than about 80 percent of allmacromolecular species present in the composition, more preferably morethan about 85%, about 90%, about 95%, and about 99%. Most preferably,the object species is purified to essential homogeneity (contaminantspecies cannot be detected in the composition by conventional detectionmethods) wherein the composition consists essentially of a singlemacromolecular species.

A “mammal” as used herein includes humans, dogs, cats, mice, rats,rabbits and livestock, for example, buffalo, horses, cattle, sheep,goats, pigs and the like. “Preconditioning” includes a brief period ofcellular stress that confers resistance to a second, more severe stress.

II. Exemplary Agents and Methods to Identify Agents Useful in theMethods of the Invention

The agents of the invention are useful to treat a mammal having(afflicted with) or at risk of having ischemia and/or reperfusioninjury. As inhibitors of cytochrome P450 enzymes were found to be usefulto inhibit ischemia and/or reperfusion injury to myocardium, theseagents, as well as others disclosed herein, may be useful to treat orprevent a wide range of indications or conditions associated withischemia and/or reperfusion injury. For example, these agents include,but are not limited to, H₂-receptor antagonists, H+/K+ATPase inhibitors,antimicrobials and antifungals, active agents including tricyclicantidepressants, serotonin reuptake inhibitor antidepressants,phenothiazine antipsychotics and benzodiazepines anxiolytic. Preferredagents include H₂-receptor antagonists, e.g., cimetidine, ranitidine,and ebrotidine; H⁺/K⁺ ATPase inhibitors, e.g., omeprazole;antimicrobials and antifungals, e.g., chloramphenicol, econazole,ketoconazole, sulfaphenazole, trimethoprim, sulfamethoxazole,clotrimazole, and miconazole; central nervous system (CNS)-active agentsincluding tricyclic antidepressants such as clomipramine, amitriptyline,and desipramine, serotonin reuptake inhibitor antidepressants such asfluoxetine, sertraline, and paroxetine, phenothiazine antipsychotics,e.g., chlorpromazine, and benzodiazepines anxiolytics, for instance,flurazepam and medazapam; nonsteroidal anti-inflammatory drugs (NSAIDs),e.g., diclofenac, flufenamine, fenoprofen, flurbiprofen, and ketoprofen;metyrapone; 7-ethoxyresorufin; HMG-CoA synthase inhibitors, e.g.,statins; sartans, and calcium channel blockers, e.g., diltiazem,verapamil, lercanidipine, nifedipine, nisoldipine, nicardipine,isradipine, nitrendipine, felodipine, and amlodipine. As describedherein, the use of inhibitors with specificity for certain cytochromeP450 enzymes rather than the use of broad spectrum inhibitors, and/orspecific doses of cytochrome P450 inhibitors which selectively inhibitmore or more cytochrome P450 enzymes, may minimize side effectsresulting from disrupting unrelated physiological processes.

A. Exemplary Methods to Identify Agents

Methods to identify agents useful in the methods of the inventioninclude in vitro and in vivo methods. In vitro methods can employ tissuecultures or isolated organs or tissues. For instance, renal epithelialcells can be cultured in vitro. To simulate ischemia, after formation ofa confluent epithelial cell sheet, the cells are washed with phosphatebuffered saline, and the monolayer is immersed in mineral oil (Meldrumet al., 2002). Exposure to mineral oil restricts cell exposure to oxygenand nutrients, and prevents metabolite washout. Simulated ischemia canalso be performed on other cell types in tissue culture, such as inisolated myocytes (Gottlieb et al., 1994; Gottlieb et al., 1996; Henryet al., 1996). To screen agents for use in inhibiting or preventingischemia, the agents may be added to the cultures before or duringischemia. Then the amount of cellular injury in control cultures versusagent exposed cultures determined. For renal ischemia, in vitrodeterminations of creatine levels may be useful to identify agents thatdecrease renal ischemic injury (Brasile et al., 2002) whiledeterminations of CK levels (e.g., using the CK EC 2.7.3.2 UV-Test kit,Sigma) may be useful to identify agents that decrease myocardialischemic injury.

Other in vitro methods to identify efficacious agents for myocardialischemia include the determination of CK release, superoxide productionand coronary flow in isolated hearts exposed to a test agent. Forinstance, hearts are excised from an anesthetized mammal such as arabbit and quickly cannulated onto a Langendorff perfusion apparatus.The heart is perfused with Krebs-Ringer buffer, e.g., for 15 to 60minutes, before ischemia/reperfusion episodes. No-flow ischemia ismaintained for a period of time, e.g., 5 to 60 minutes, and reperfusionis accomplished by restoring flow, e.g., for 5 to 60 minutes. Ischemicpreconditioning can be induced by, for example, three 5 minute cycles ofno-flow ischemia and reperfusion immediately preceding the regularischemia and reperfusion. The agent to be tested may be added prior toischemia induction, at the onset of ischemia, at the onset ofreperfusion, or any combination thereof. CK release in control versustreated hearts may be measured using the CK EC 2.7.3.2 UV-Test kit(Sigma) per the manufacturer's instructions.

Similarly, isolated kidneys may be used to screen agents in a renalmodel of transplantation (see Brasile et al., 2002).

Superoxide production can be assessed via the conversion ofdihydroethidium (DHE) to ethidium (Miller et al., 1998). Tissue, e.g.,heart, slices (1 mm thick) are stained in 2 μM DHE (Molecular Probes,Eugene, Oreg.) in PBS in the dark at 37° C. for 20 minutes. Sectionsimaged on an ultraviolet transilluminator (Fisher Scientific) with aKodak DC120 digital camera (Kodak) using Kodak Digital Science 1Dsoftware (Kodak) are saved as TIFF files and analyzed using AdobePhotoshop 5.5. The relative fluorescence intensity reflecting superoxideproduction was quantified as the ratio of fluorescent (white) pixels tothe total heart area. Statistical analysis was performed between groupsusing ANOVA. Heart slices can also be used to detect the size of theinfarcted region (see Examples).

Agents may also be tested for the ability to inhibit one or morecytochrome P450 enzymes in in vitro assays (see Example II).

The agents of the invention can be assayed for their effect inprotecting against or inhibiting or treating reperfusion injuryassociated with myocardial, intestinal, renal, or cerebral ischemia inanimal models. Myocardial infarction is the result of acute closure of acoronary vessel usually due to thrombosis secondary to rupture of anatherosclerotic plaque. The damage to the adjacent myocardium andresultant heart failure is secondary to the period of ischemia and thedamage caused during the reperfusion period. Reperfusion injuries areassociated with increased oxygen free radicals and inflammatorymediators. Exemplary animal models of myocardial ischemia are disclosedin Zhang et al., 1999; Ning et al., and the Examples herein.

Both rats and rabbits have been used as models for intestinal ischemia(Kuenzler et al., 2002; Caglayan et al., 2002). In a rabbit intestinalischemia/reperfusion model, for instance, the animal undergoeslaparotomy, and then an atraumatic microvascular clamp is placed acrossthe mesenteric artery, allowing occlusion of the related vein (Caglayanet al., 2002). The marginal vessels at both ends of the segment aredivided and ligated, and the intramural collateral blood flow is stoppedwith atraumatic intestinal clamps (Caglayan et al., 2002). Mesentericischemia is confirmed when the mesenteric pulsations are lost and theintestinal segment becomes pale. The bowel is then returned to theabdominal cavity and the incision is closed. After the desired ischemicperiod (e.g., 60 minutes), a relaparotomy is performed and themicrovascular clamp on the artery is removed to allow reperfusion.Injury can be detected by blood levels of intracellular enzymes, e.g.,aspartate aminotransferase, CK, and lactate dehydrogenase (Caglayan etal., 2002), or galactose or glycine absorption (Kuenzler et al., 2002).Also, intestinal mucosal lesions can be measured as described in Chin etal., 1970.

Likewise, renal ischemia can be induced in rodent models by clamping ofone or both renal arteries, and reperfusion induced by removing theclamps (Yoshida et al., 2002; Miyazawa et al., 2002). Levels of creatineand neutrophil, intermediate T cell and/or polymorphonuclear lymphocytesin control animals and animals contacted with a test agent can then bedetermined (Brasile et al., 2002; Miyazawa et al., 2002). Cerebralischemia can be induced transiently in the rat by, for instance, themethod of middle cerebral artery occlusion (Loy et al., 2002; Longa etal., 1989).

A porcine model for sepsis associated with hepatic ischemia andreperfusion injury may be employed to screen agents (Lemaire et al.,1994). In this model, a portacaval shunt is created, and then liverischemia is achieved by clamping the hepatic pedicle (i.e., the portalvein and the common hepatic artery). Reperfusion is achieved by closingthe portacaval shunt. A rat model of chronic sepsis which employs cecalligation and perforation, may also be employed (Scott et al., 2002).

Development of atherosclerosis is a complex process involving smoothmuscle cells, endothelial cells and inflammatory cells, and, inparticular, monocyte-derived tissue macrophages, B or T cells, andreactive oxygen species are believed to promote atherosclerosis. Onceendothelial cells are activated, they express adhesion moleculesimportant for the extravasation of inflammatory cells. The activatedendothelial cells express, among other adhesion molecules, E-selectin,P-selectin, and ICAM-1, which in turn participate in the extravasationof leukocytes. Potent pro-inflammatory cytokines were also expressed atthe sites of incipient vascular lesions. TNF-α, IL-1, as well as severalchemokines including IL-8 and MCP-1, have been detected at elevatedlevels in atherosclerotic lesions.

It is now well accepted that the acute stability of vascular lesions isa more important determinant of short-term, e.g., less than severalyears, risk of myocardial infarction, than is total plaque burden.Inhibitors of cytochrome P450 enzymes may be useful to inhibit orprevent atherosclerosis, e.g., by reducing plaque burden or lesiondevelopment, or increasing plaque stability, and thus reduce the risk ofmyocardial infarction. Animal models of atherosclerosis are known to theart and may be employed to screen for agents with desirable properties(see, e.g., Post et al., 2002; Berg et al., 2002; George et al., 2002;Nishimoto et al., 2002).

Hypertension is a risk factor for atherosclerosis. To determine whetheran agent of the invention is useful to inhibit or treat hypertension, arabbit model is employed. New Zealand white rabbits are fed anatherogenic diet for three weeks to induce plaque formation. One half ofeach group of rabbits is administered a test agent. Aortic coarctationis created in one group of the rabbits by wrapping a Dacron band aroundthe midportion of the descending thoracic aorta (stenosis group).Another group of rabbits undergo the banding technique without aorticconstriction. Yet another group of rabbits serve as controls.

To determine whether an agent is useful to inhibit ischemia orreperfusion injury associated with vascular interventional procedures, anumber of animal models may be employed (see, e.g., Wilczek et al.,2002; Maffia et al., 2002; Yasuda et al., 2002; Kipshidze et al., 2002;Yoon et al., 2002).

B. Exemplary In Vitro Methods to Identify Cytochrome P450 InhibitorsUseful to Treat Cardiac Indications

Cardiac tissue contains cardiomyocytes, which provide the mechanicalforce, consume most of the oxygen and energy of the heart, and containmost of the mitochondria in the heart. Cardiac tissue also containsendothelial cells, which line the capillaries of the heart, which cellsproduce nitric oxide and other factors that regulate vasomotor tone andcardiac contractility. Endothelial cells, while equal in number tocardiomyocytes in the heart, represent about 1/10 the mass of the heart.

Cytochrome P450 enzymes (EC 1.14.14.1, non-specific monooxygenases) areheme proteins that are defined by a characteristic absorption spectrum,where the Fe (II) CO complex has a characteristic Soret band near 450 nmdue to axial ligation with a cysteine thiolate of the protein. Thecytochrome P450 enzymes are membrane-bound, terminal oxidases that existin a multi-enzyme system that also includes a FAD/FMN-containingNADPH-cytochrome P450 reductase and cytochrome b₅. Members of thecytochrome P450 enzyme superfamily oxidize, peroxidize and/or reducecholesterol, steroids, arachidonic acid, bradykinin, vitamins,xenobiotics and numerous therapeutic substances in an oxygen- andNADPH-dependent manner. Some cytochrome P450 isoforms are specific intheir choice of substrates but many, particularly those in theendoplasmic reticulum, catalyze a large number of reactions.

There are many different cytochrome P450 enzymes and there can be >30cytochrome P450 genes expressing their products in a single organism,and many of these are concurrently produced in a single tissue. Thecytochrome P450 genes are classified on the basis of their codingsequence and sequence homology (Nebert et al., 1991). Cytochrome P450proteins from all species that possess 40% sequence identity or greaterare included in the same family, which is designated by an Arabicnumber. Proteins that share greater than 55% homology are then groupedtogether in the same subclass as designated by a capital letter; thefinal number identifies specific gene products (Coon et al., 1992).

The vast majority of cytochrome P450 enzymes are expressed in the liver,with significantly lower levels being expressed in extra-hepatictissues. However, some cytochrome P450 enzymes are predominantlydetected in the heart, vasculature, gastrointestinal tract, kidney andlung (Oyekan et al., 2002; Scarborough et al., 1999).

Cytochrome P450 distribution differs between right and left ventricle,and also differs according to cell type. Cytochrome P450 monooxygenasesare present in both cardiac endothelial cells and cardiomyocytes, andare important to the regulation of coronary flow, and production ofreactive oxygen species (ROS), e.g., superoxide, and vasoactiveeicosanoids. Eicosanoids in turn regulate intracellular signaltransduction pathways, plasma membrane ion channels, and potentially themitochondrial ATP-sensitive potassium channel (mito KATP) that isimplicated in cardioprotection by preconditioning.

Inhibitors of cytochrome P450 enzymes may be selected based on theirspecificity, e.g., fluvastatin is a potent inhibitor of CYP2C9(Scripture et al., 2001), while lovastatin, atorvastatin, simvastatin,and derivastatin inhibit CYP2C19 and CYP3A4, and atorvastatin,cerivastatin, and fluvastatin are moderate inhibitors of CYP2D6. Toidentify selective inhibitors of particular cytochrome P450 isozymes, aswell as to identify cytochrome P450 isozymes that are responsible forreperfusion injury in heart tissue, for instance, those that metabolizearachidonic acid and linoleic acid, various assays including thosedescribed herein and/or assays with isozyme-specific substrates and/orinhibitors, may be employed. Cytochrome P450 isozymes are rather looselycoupled to the reductase. This inefficient coupling results ingeneration of the byproduct superoxide, which is produced to a greaterextent by some isozymes than others. After hypoxia or exposure tooxidative stress (e.g., hydrogen peroxide), some cytochrome P450isozymes become even further uncoupled and generate superoxide even morevigorously. It was observed that H9c2, a rat embryonic cell line, andneonatal rat cardiomyocyces, undergo apoptosis and produce superoxide inresponse to hydrogen peroxide, which can be rescued by treatment with acytochrome P450 inhibitor such as sulfaphenazole. Those resultssuggested that hydrogen peroxide treatment uncouples cytochrome P450isozymes, causing increased ROS production leading to apoptosis.

1. Endothelial Cells

Endothelial cells and cardiomyocytes are employed in assays to identifycytochrome P450 isozymes that are responsible for reperfusion injury inheart tissue, as the cytochrome P450 isozymes in endothelial cells maybe different than those in cardiomyocytes. Thus, endothelial cells, suchas human coronary artery endothelial cells (HAEC) and/or rat heartendothelial cells (obtained by collagenase perfusion and dissociation ofthe rat heart), and cardiomyocytes are screened for cytochrome P450activity, particularly their ability to generate superoxide, and theirsusceptibility to cytochrome P450 inhibition, e.g., cardioprotectivecytochrome P450 inhibitors. For example, HAECs, rat endothelial cellsand/or adult cardiomyocytes are screened for the ability of a cytochromeP450 inhibitor to rescue those cells from H₂O₂-induced apoptosis.Apoptosis is scored by reduction of the tetrazolium dye, MTT, using aspectrophotometric plate reader. MTT is reduced to a colored product bydehydrogenases in living cells; therefore the MTT assay scores viablecells. Results are verified by fluorescence microscopy of live cellsusing Rhodamine 123 to stain mitochondria with normal membranepotential, and Hoechst 33432 to stain nuclei. Dihydroethidium isemployed as a readout for superoxide production.

2. Isozyme Specific Inhibitors

HAECs are employed with Gentest substrates to detect specific humancytochrome P450 isozymes and the efficacy of various cytochrome P450inhibitors. The specific isozymes known to be present in human hearttissue include those listed in Table 1. Substrates are commerciallyavailable for CYP 1A, 2B, 2C, 2D, 2E, and 4A isozymes. Arachidonic acidmetabolites can be detected using LC-MS-MS. A close correlation betweenprotective efficacy by a subset of cytochrome P450 inhibitors and theisozyme that is sensitive to the same subset of inhibitors implicates aparticular isozyme as responsible for peroxide-induced injury. The sameisozyme is also likely responsible for reperfusion injury in the heart.TABLE 1 CYP isozymes in human heart. Physiologic Activity 1A1 metabolismof tryptamine 2B6/7 arachidonic acid epoxidation 2C8/19 arachidonic acidepoxidation, phospholipid hydrolysis 2D6 tryptamine to tryptophol 2J2arachidonic acid epoxidation 4B1 fatty acid ω-hydroxylation 4A10* lipidperoxidation 2E1* arachidonic acid ω-hydroxylation, lipid peroxidation1B1* 17-beta estradiol hydroxylation 2F2* natural substrate unknown

If cardioprotection correlates more closely with protection foroxidative stress in isolated cardiomyocytes, then it is likely that thedeleterious cytochrome P450 isozymes are present within thecardiomyocytes rather than endothelial cells. To measure superoxideproduction in frozen heart slices, unfixed human heart cryostat sectionsare stained with dihydroethidium to detect basal superoxide production.Parallel slices are treated with candidate cytochrome P450 inhibitors toassess their ability to suppress superoxide production. CytochromeP450-dependent ROS production may be increased by first pretreatingslides with hydrogen peroxide.

The cytochrome P450 isozyme(s) responsible for reperfusion injury in therat heart is highly conserved across species, such as CYP 1B1, and thatisozyme is present in human heart tissue, it is likely that thecorresponding isozyme in humans is sensitive to the candidateinhibitors. Candidate cytochrome P450 isozymes in rat heart that areinhibited by chloramphenicol and sulfaphenazole can be detected usingAMMC (a Gentest product) as a substrate. AMMC demethylase activity isinhibited by chloramphenicol and sulfaphenazole in concentration rangesthat correspond closely to those needed for protection in the perfusedheart model. While CYP2D2 and 2D6 are the most common enzymes thatdemethylate AMMC, they were not inhibited by sulfaphenazole in arecombinant system.

3. Vascular Tone in Coronary Artery Rings

During reperfusion, vasodilation is important to allow adequatere-oxygenation, while vasoconstriction perpetuates ischemia in distaltissues. The results described herein, demonstrating enhanced coronaryflow during reperfusion, suggest that vasodilation is a feature of atleast some cytochrome P450 inhibitors. To identify agents that conferprotection in the heart, coronary artery ring segments from explantedvessels, e.g., human vessels (such as those obtained at the time ofcoronary artery bypass graft), can be employed as they contract inresponse to superoxide and relax in response to nitric oxide. Vasculartone is therefore a reflection of the balance of superoxide and nitricoxide. Inhibition of superoxide production from cytochrome P450 enzymesresults in vasorelaxation which can be measured with a tensiometer. Ifnecessary, the ring segment can first be subjected to ischemia andreperfusion by modifying the organ bath perfusion buffer to exacerbatesuperoxide production. As a correlation has been established betweenvasorelaxation and reduction of infarct size, cytochrome P450 inhibitorsthat enhance vasorelaxation likely reduce infarct size.

4. Papillary Muscle Segments

Papillary muscle segments from human heart may be removed at time ofsurgery and subjected to ischemia/reperfusion in an organ bath. Agentsuseful in the invention limit superoxide production (detected by DHEconversion) and reduce apoptosis (detected in histologic sections byTUNEL assay, see Gottlieb, 1994).

5. White Blood Cells and Platelets

One aspect of reperfusion injury is mediated by inflammation, includingactivated T cells, monocytes, mast cells, and likely also B cells andneutrophils. T cells can be activated by free radicals and therefore arelikely to become activated during reperfusion. Therefore, peripheralwhite blood cells may be used to screen for efficacy of cytochrome P450inhibitors. Lymphocytes, neutrophils, and monocytes are obtained fromwhole blood using standard methods. Activation is assessed by flowcytometry after exposure to the appropriate stimulus, usingactivation-specific antibodies. Agents that suppress ROS production fromactivated white blood cells are likely to be beneficial in reperfusioninjury of any organ.

Platelet aggregation is another aspect of ischemia/reperfusion injury.It has been suggested that platelet activation may be triggered by ROSand arachidonic acid metabolites that may be generated by cytochromeP450 enzymes. Therefore, inhibition of cytochrome P450 enzymes inplatelets may suppress aggregation, an effect which can be tested usingplatelet aggregometry and purified platelets from human blood, which areincubated in the presence or absence of various cytochrome P450inhibitors.

D. Exemplary Agents

A number of agents may find use in the methods of the inventionincluding, but not limited to, agents such as H₂-receptor antagonists,e.g., cimetidine, ranitidine, and ebrotidine; H⁺/K⁺ ATPase inhibitors,e.g., omeprazole; antimicrobials and antifungals, e.g., chloramphenicol,econazole, ketoconazole, sulfaphenazole, trimethoprim, sulfamethoxazole,clotrimazole, and miconazole; CNS-active agents including tricyclicantidepressants such as clomipramine, amitriptyline, and desipramine,serotonin reuptake inhibitor antidepressants such as fluoxetine,sertraline, and paroxetine, phenothiazine antipsychotics, e.g.,chlorpromazine, and benzodiazepines anxiolytics, for instance,flurazepam and medazapam; NSAIDs, e.g., diclofenac, flufenamine,fenoprofen, flurbiprofen, and ketoprofen; metyrapone; 7-ethoxyresorufin;HMG-CoA synthase inhibitors, e.g., statins; sartans, and calcium channelblockers, e.g., diltiazem, verapamil, lercanidipine, nifedipine,nisoldipine, nicardipine, isradipine, nitrendipine, felodipine, andamlodipine, as well as agents that inhibit mitochondrial superoxideproduction, e.g., complex I inhibitors such as idebenone, rotenone,p-hydroxy-mercuribenzoat, rolliniastatin-2, capsaicin and amytal;complex III inhibitors, e.g., myxothiazol, antimycin A and mucidin(strobilurin A); and agents that inhibit superoxide production at othersites, for instance, xanthine oxidase inhibitors (e.g., allopurinol),and NAD(P)H oxidase inhibitors (e.g., apocynin and diphenyleneiodonium).

In particular, agents useful in the practice of the invention include,but are not limited to, agents that inhibit the amount (level) oractivity of one or more cytochrome P450 enzymes. Exemplary inhibitors ofcytochrome P540 enzymes may include H2-receptor antagonists, e.g.,cimetidine, ranifidine, and ebrotidine; H⁺/K⁺ ATPase inhibitors, e.g.,omeprazole; antimicrobials and antifungals, e.g., chloramphenicol,econazole, ketoconazole, sulfaphenazole, clotrimazole, and miconazole;CNS-active agents including tricyclic antidepressants such asclomipramine, amitriptyline, and desipramine; serotonin reuptakeinhibitor antidepressants such as fluoxetine, sertraline, andparoxetine; phenothiazine antipsychotics, e.g., chlorpromazine;benzodiazepines anxiolytics, for instance, flurazepam and medazapam;NSAIDs, e.g., diclofenac, flufenamine, fenoprofen, flurbiprofen, andketoprofen, metyrapone, 7-ethoxyresorufin: HMG-CoA synthase inhibitors,e.g., statins; sartans, and calcium channel blockers, e.g., diltiazem,verapamil, lercanidipine, nifedipine, nisoldipine, nicardipine,isradipine, nitrendipine, felodipine, and amlodipine.

Further, agents that can act as substrates or inhibitors of one or asubset of cytochrome P450 enzymes including, but not limited to, thecytochrome 450 1A family, e.g., 1A1 or 1A2, the cytochrome P450 2Bfamily, e.g., 2B6 and 2B7, the cytochrome P450 2C family, e.g., 2C8-19such as 2C9 or 2C19, the cytochrome P450 2D family, e.g., 2D6, thecytochrome P450 2E family, e.g., 2E1, the cytochrome P450 3A family,e.g., 3A4, 3A5 and 3A7, and the cytochrome P450 4B family, e.g., 4B1,may find use in the methods of the invention. For instance, resveratrolis an inhibitor of 1A1. For example, substrates of 1A2 include, but arenot limited to, amitriptyline, caffeine, clomipramine, clozapine,cyclobenzaprine (Flexeril®), estradiol, fluvoxamine, haloperidol,imipramine N-DeMe, mexiletine, naproxen, ondansetron, phenacetin,acetaminophen, propranolol, riluzole, ropivacaine, tacrine,theophylline, veraprimil, warfarin, zileuton, and zolmitriptan.Inhibitors of 1A2 include, but are not limited to, amiodarone,cimetidine, fluoroquinolones, fluvoxamine, furafylline, methoxsalen,mibefradil and ticlopidine.

Substrates of 2B6 include bupropion, cyclophosphamide, ifosfamide and aninhibitor of 2B6 includes thiotepa. Substrates of 2C8 include TCA,diazepam and verapamil and cimetidine is an inhibitor of 2C8.

Substrates of 2C9 include NSAIDs such as diclofenac, ibuprofen,suprofen, meloxicam and S-naproxen, oral hypoglycemic agents such astolbutamide and glipizide, angiotensin II blockers such as losartan(activated) and irebesartan; amitriptyline, celecoxib, fluoxetine,fluvastatin, glyberide, phenytoin, rosiglitazone, tamoxifen, torsemide,tolbutamide, piroxican, irbesartan, verapamil, dextromethorphan, andS-warfarin. Inhibitors of 2C9 include, but are not limited to,amiodarone, cimetidine, chloramphenicol, fluconazole, fluvastatin,fluvoxamine, isoniazid, ketoconazole, metronidazole, ritonavir,lovastatin, paroxetine, phenylbutazone, probenicid, sertraline,sulfamethoxazole, sulfaphenazole, teniposide, ticlopidine, trimethoprim,and zafirlukast.

Substrates of 2C19 include proton pump inhibitors such as lansoprazole,omeprazole, pantoprazole, and E-3810; anti-epileptics such as diazepam,nophenytoin(O), S-mephenytoin, and phenobarbitone, amitriptyline,citalopram, clomipramine, cyclophosphamide, hexobarbital, imipramineN-DeME, indomethacin, R-mephobarbital, mocolobemide, nelfinavir,nilutamide, primidone, progesterone, proguanil, propranolol, teniposideand R-warfarin. Inhibitors of 2C19 include cimetidine, felbamate,fluoxetine, fluvoxamine, indomethacin, ketoconazole, lansoprazole,modafinil, omeprazole, paroxetine, probenicid, ticlopidine, andtopiramate.

Substrates of 2D6 include, but are not limited to, beta blockers such ascaredilol, S-metoprolol, propafemone, timolol; antidepressants such asamitriptyline, clomipramine, desipramine, imipramine, paroxetine;antipsychotics such as haloperidol, perphenazine, risperidone,thioridazine, alprenolol, amphetamine, bufuraolol, chlorpheniramine,chlorpromazine, codeine, debrisoquine, dexfenfluramine,dextromethorphan, encainide, flecainide, fluoxetine, fluvoxamine,lidocaine, metoclopramide, methoxyamphteamine, mexiletine, notriptyline,minaprine, ondansetron, perhexiline, phenacetin, phenformin,propranolol, quanoxan, sparteine, tamoxifen, tramadol, and venlafaxine.Inhibitors of 2D6 include, but are not limited to, amiodarone, celcoxib,chlorpromazine, chlorpheniramine, cimetidine, clomipramine, cocaine,doxorubicin, fluxetine, halofantrine, red-haloperidol, levomepromazine,metoclopramide, methadone, mibefradil, moclobemide, paroxetine,quinidine, ranitidine, tironavir, sertraline and terbinafine.

Substrates of 2E1 include, but are not limited to, anesthetics such asenflurane, halothane, isoflurane, methoxyflurane, sevoflurane, andacetaminophen, aniline, benzene, chlorzoxazone, ethanol, N,N-dimethylformamide, and theophylline. Inhibitors of 2E1 include, but are notlimited to, diethyldithiocarbamate and disulfan.

Substrates of 3A 4, 5 and 7 include, but are not limited to, macrolideantibiotics such as clarithromycin, erythromycin, anti-arrhythmics suchas quinidine, benzodiazepines such as alprazolam, diazepam, midazolam,and triazolam, immune modulators such as cyclosporine, tarolimus andFK506, antivirals such as indinavir, nelfinavir, ritonavir, andsaquinavir, prokinetic cisaprine, antihistamines such as astemizole,chlorpheniramine, and terfenidine, calcium channel blockers such asamlodipine, diltiazem, felodipine, lercanidipine, nifedipine,nisoldipine, nitrendipine and verapamil, HMG CoA reductase inhibitorssuch as atorvastatin, cerivastatin, and lovastatin, estradiol,hydrocortisone, progesterone, testosterone, alfentanyl, buspirone,caffeine, cocaine, dapsone, codeine, N-demethylation, dextromethorphan,fentanyl finasteride, haloperidol, lidocaine, methadone, odanstron,pimozide, propranolol, quinine, salmeterol, sildenafil, tamoxifen,taxol, terfenadine, trazodone, vincristine, zaleplon, and zolpidem.Inhibitors of 3A 4, 5 and 7 include but are not limited to delaviridine,indinavir, nelfmavir, ritonavir, saquinavir, amiodarone, cimetidine,ciprofloxacin, clarithromycin, diethyl-dithiocarbamate, diltiazem,erythromycin, fluconazole, fluvoxamine, gestodene, itaconazole,ketoconazole, mifepristone, nefazodone, norfloxacin, norfluoxetine,mibefradil, and troleandomycin.

In one embodiment, the agent is selected from the group consisting ofcimetidine, chloramphenicol, econazole, ketoconazole, sulfaphenazole,clotrimazole, miconazole, trimethoprim, sulfamethoxazole ortrimethoprim/sulfamethoxazole.

In one embodiment, preferred agents do not substantially inhibit proteinsynthesis, e.g., in mitochondria. In one embodiment, the agent to beemployed in the methods of the invention is not chloramphenicol (see Heet al., 2001).

III. Exemplary Indications or Conditions to be Treated with theTherapeutic Agents

To treat or inhibit reperfusion injury in a mammal, one or more agentsof the invention may be administered after the onset of ischemiaassociated with any condition, such as those associated with productionof ROS. The one or more agents may also be administered to a mammal atrisk of having ischemia and reperfusion injury. For instance, theischemia or condition can be associated with or caused by acutemyocardial infarction, elective angioplasty, coronary artery bypassgraft, surgery involving cardiac bypass or organ or tissuetransplantation, e.g., cardiac transplantation, stroke, head trauma,drowning, sepsis, cardiac arrest, drowning or shock, atherosclerosis,hypertension, cocaine-induced heart disease, smoking-induced heartdisease, heart failure, pulmonary hypertension, hemorrhage, capillaryleak syndrome (such as child and adult respiratory distress syndrome),multi-organ system failure, a state of low colloid oncotic pressure(such as starvation, anorexia nervosa, or hepatic failure with decreasedproduction of serum proteins), anaphylaxis, hypothermia, cold injury,e.g., due to hypothermic perfusion, frostbite, hepatorenal syndrome,delirium tremens, a crush injury, mesenteric insufficiency, peripheralvascular disease, claudication, burn, electrocution, excessivedrug-induced vasodilation, excessive drug-induced vasoconstriction,tissue rejection after transplantation, graft versus host disease,radiation exposure, e.g., during fluoroscopy or radiographic imaging, orexposure to high energy, e.g., exposure to laser light. Excessivedrug-induced vasodilation can be caused by, for instance, nitroprusside,hydralazone, dyazoxide, a calcium channel blocker, or a generalanesthetic. Excessive drug-induced vasoconstriction can be caused by,for instance, neosynephrine, isoproterenol, dopamine, dobutamine, orcocaine.

In one embodiment, one or more agents of the invention are employed totreat or inhibit reperfusion injury associated with a vascularinterventional procedure. Vascular interventional procedures include,but are not limited to, those which employ a stent, e.g., a coatedstent, angioplasty catheter (percutaneous transluminal angioplasty),laser catheter, atherectomy catheter, e.g., TEC and DVI, angioscopydevice, beta or gamma radiation catheter, intravascular ultrasounddevice, rotational atherectomy device, radioactive balloon, heatablewire, heatable balloon, biodegradable stent strut, or biodegradablesleeve.

For instance, the agents of the invention are useful to inhibit or treatindications associated with upregulation of cytochrome P450 enzymesincluding but not limited to hypertension, obesity, drug, e.g., cocaine,use, heart failure, and in tobacco smokers and diabetics, as smokers anddiabetics are prone to more severe coronary artery disease and stroke.In one embodiment of the invention, patients with these indications arechronically treated with one or more agents of the invention to decreasetheir risk of an adverse cardiovascular event. In another embodiment,one or more agents of the invention are administered chronically to slowdown the progression of heart failure. For example, cardiac conditionsmay be inhibited or treated with inhibitors of cytochrome P450 enzymesexpressed in the heart, e.g., CYP 1A1, 2B6/7, 2C8-19, e.g., 2C9, 2D6,2E1, and 4B1. For instance, as heart failure is associated withupregulation of CYP2J2, CYP1B1, CYP2E1, CYP4A10, and CYP2F2, heartfailure patients may be treated with one or more inhibitors of one ormore of those enzymes. As drug use induces CYP 1A1 and 2J2 in cardiactissues, one or more inhibitors of those enzymes may be cardioprotectivein drug users. Also, as CYP4A10 and CYP2E1 are upregulated in obesepatients, inhibitors of those enzymes may likewise be efficacious.

Moreover, patients who experience one myocardial infarction have a highprobability of having subsequent myocardial infarctions. Therefore, inone embodiment, patients who survive a myocardial infarction arechronically treated with one or more agents of the invention to decreasetheir risk of recurrence. Similarly, one or more agents of the inventionmay be administered chronically to patient with stroke or peripheralvascular disease. Further, as cytochrome P450 enzyme expression issexually dimorphic and men are at increased risk of cardiovasculardisease, selective inhibition of male-specific cytochrome P450 isozymesmay be useful to decrease cardiac risk.

In addition, since cytochrome P450 enzymes can be triggered to generateexcessive reactive oxygen species (ROS) in response to hypoxia oroxidative stress, one or more agents of the invention may beadministered to a mammal before, during, or after chemotherapy,radiation therapy, or laser treatments, or to a mammal diagnosed withalcohol intoxication, burn injuries, sepsis, retinopathy of thepremature, hyperoxia, infantile respiratory distress syndrome,necrotizing enterocolitis, intravascular hemolysis, acute respiratorydistress syndrome, Alzheimers disease, Parkinson's disease, and relatedneurodegenerative diseases, autoimmune diseases such as lupus andrheumatoid arthritis, and chronic inflammatory processes such asatherosclerosis. Inhibition of specific cytochrome P450 isozymes inthese conditions decreases ROS production and attenuates tissue damagethat contributes to pathogenesis.

Thus, in one embodiment, the therapeutic agents can be usedprophylactically in a mammal after a cardiovascular event, or in amammal at risk of an ischemic event including but not limited to asmoker, diabetic, a mammal with hypertension, dyslipidemia, or a familyhistory of vascular events, as well as in a mammal with documentedcoronary disease, peripheral vascular disease, or cerebrovasculardisease, or in a mammal prior to diagnostic or therapeutic radiology, orprior to laser therapy, for instance, cutaneous or retinal lasertherapy.

IV. Dosages, Formulations and Routes of Administration of TherapeuticAgents

The therapeutic agents of the invention, including theirpharmaceutically acceptable salts, are administered so as to achieve adesired effect, e.g., inhibit or reduce ischemia and/or reperfusioninjury, increase cardiac contractility, increase coronary blood flow,reduce superoxide production, or reactive oxygen specie productionincluding lipid peroxidation, reduce CK release, inhibit or reduceinfarct size, and/or inhibit or decrease the level or activity of one ormore cytochrome P450 isozymes. To achieve the desired effect(s), theagent, or a combination thereof, may be administered as single ordivided dosages. The amount administered will vary depending on variousfactors including, but not limited to, the agent chosen, the indicationor condition to be prevented or treated, the weight, physical condition,health, and age of the mammal, and whether prevention or treatment is tobe achieved. Such factors can be readily determined by the clinicianemploying animal models or other test systems that are available in theart. For agents which inhibit cytochrome P450 enzymes, a preferredamount is one which is chosen to selectively inhibit one or morecytochrome P450 enzymes. For example, the amount of clotrimazole orproadifen employed in the methods of the invention does not include thehigh doses described in Zhang et al. (1999).

Thus, the administration of the therapeutic agents in accordance withthe present invention may be in a single dose, in multiple doses, in acontinuous or intermittent manner, depending, for example, upon therecipient's physiological condition, whether the purpose of theadministration is therapeutic or prophylactic, and other factors knownto skilled practitioners. The administration may be prophylactic in apatient at risk of ischemic and/or reperfusion injury, e.g., a patientat risk of myocardial infarction may self-administer an agent of theinvention, or in response to certain symptoms associated with ischemicand/or reperfusion injury in an ambulance or emergency room prior toclinical confirmation of the injury. Other conditions for whichprophylactic administration of the therapeutic agents may be indicatedinclude but are not limited to smokers, diabetics, a mammal withhypertension, dyslipidemia, or a family history of vascular events, aswell as in mammals with documented coronary disease, peripheral vasculardisease, or cerebrovascular disease, and/or in a mammal after acardiovascular event, prior to diagnostic or therapeutic radiology, orprior to laser therapy, for instance, cutaneous or retinal lasertherapy. The administration of the agents of the invention may beessentially continuous over a preselected period of time or may be in aseries of spaced doses. Both local and systemic administration iscontemplated.

To prepare the composition, agents are synthesized or otherwiseobtained, purified as necessary or desired and then optionallylyophilized and stabilized. The agent can then be adjusted to theappropriate concentration, and optionally combined with other agents.

Thus, one or more suitable unit dosage forms comprising the therapeuticagents of the invention can be administered by a variety of routesincluding oral, parenteral (including subcutaneous, intravenous,intramuscular and intraperitoneal), rectal, dermal, buccal, mucosal,transdermal, intrathoracic, intrapulmonary and intranasal (respiratory)routes. The therapeutic agents may also be formulated for sustainedrelease (for example, using microencapsulation, see WO 94/07529, andU.S. Pat. No. 4,962,091). The formulations may, where appropriate, beconveniently presented in discrete unit dosage forms and may be preparedby any of the methods well known to the pharmaceutical arts. Suchmethods may include the step of mixing the therapeutic agent with liquidcarriers, solid matrices, semi-solid carriers, finely divided solidcarriers or combinations thereof, and then, if necessary, introducing orshaping the product into the desired delivery system. In general, suchdoses and dosage forms comprise an amount of at least one of the agentsof the invention effective to treat or prevent the clinical symptoms ofa specific indication or condition. Any statistically significantattenuation of one or more symptoms of an indication or condition thathas been treated pursuant to the method of the present invention isconsidered to be a treatment of such indication or condition within thescope of the invention.

When the therapeutic agents of the invention are prepared for oraladministration, they are generally combined with a pharmaceuticallyacceptable carrier, diluent or excipient to form a pharmaceuticalformulation, or unit dosage form. For oral administration, the agentsmay be present as a powder, a granular formulation, a solution, asuspension, an emulsion or in a natural or synthetic polymer or resinfor ingestion of the active ingredients from a chewing gum. The activeagents may also be presented as a bolus, electuary or paste. Orallyadministered therapeutic agents of the invention can also be formulatedfor sustained release, e.g., the agents can be coated,micro-encapsulated, or otherwise placed within a sustained deliverydevice. The total active ingredients in such formulations comprise from0.1 to 99.9% by weight of the formulation.

Pharmaceutical formulations containing the therapeutic agents of theinvention can be prepared by procedures known in the art usingwell-known and readily available ingredients. For example, the agent canbe formulated with common excipients, diluents, or carriers, and formedinto tablets, capsules, solutions, suspensions, powders, aerosols andthe like. Examples of excipients, diluents, and carriers that aresuitable for such formulations include buffers, as well as fillers andextenders such as starch, cellulose, sugars, mannitol, and silicicderivatives. Binding agents can also be included such as carboxymethylcellulose, hydroxymethylcellulose, hydroxypropyl methylcellulose andother cellulose derivatives, alginates, gelatin, andpolyvinyl-pyrrolidone. Moisturizing agents can be included such asglycerol, disintegrating agents such as calcium carbonate and sodiumbicarbonate. Agents for retarding dissolution can also be included suchas paraffin. Resorption accelerators such as quaternary ammoniumcompounds can also be included. Surface active agents such as cetylalcohol and glycerol monostearate can be included. Adsorptive carrierssuch as kaolin and bentonite can be added. Lubricants such as talc,calcium and magnesium stearate, and solid polyethyl glycols can also beincluded. Preservatives may also be added. The compositions of theinvention can also contain thickening agents such as cellulose and/orcellulose derivatives. They may also contain gums such as xanthan, guaror carbo gum or gum arabic, or alternatively polyethylene glycols,bentones and montinorillonites, and the like.

For example, tablets or caplets containing the agents of the inventioncan include buffering agents such as calcium carbonate, magnesium oxideand magnesium carbonate. Caplets and tablets can also include inactiveingredients such as cellulose, pregelatinized starch, silicon dioxide,hydroxy propyl methyl cellulose, magnesium stearate, microcrystallinecellulose, starch, talc, titanium dioxide, benzoic acid, citric acid,corn starch, mineral oil, polypropylene glycol, sodium phosphate, zincstearate, and the like. Hard or soft gelatin capsules containing atleast one agent of the invention can contain inactive ingredients suchas gelatin, microcrystalline cellulose, sodium lauryl sulfate, starch,talc, and titanium dioxide, and the like, as well as liquid vehiclessuch as polyethylene glycols (PEGs) and vegetable oil. Moreover,enteric-coated caplets or tablets containing one or more agents of theinvention are designed to resist disintegration in the stomach anddissolve in the more neutral to alkaline environment of the duodenum.

The therapeutic agents of the invention can also be formulated aselixirs or solutions for convenient oral administration or as solutionsappropriate for parenteral administration, for instance byintramuscular, subcutaneous, intraperitoneal or intravenous routes. Theadministration may be accomplished via a needle, a catheter, e.g., aballoon catheter, which is distal to the region to be treated, forinstance, a coronary artery, a stent or a stent coated with the agent,such as an intracoronary stent, which may be useful for sustainedrelease of the agent. The pharmaceutical formulations of the therapeuticagents of the invention can also take the form of an aqueous oranhydrous solution or dispersion, or alternatively the form of anemulsion or suspension or salve.

Thus, the therapeutic agents may be formulated for parenteraladministration (e.g., by injection, for example, bolus injection orcontinuous infusion) and may be presented in unit dose form in ampules,pre-filled syringes, small volume infusion containers or in multi-dosecontainers. As noted above, preservatives can be added to help maintainthe shelve life of the dosage form. The active agents and otheringredients may form suspensions, solutions, or emulsions in oily oraqueous vehicles, and may contain formulatory agents such as suspending,stabilizing and/or dispersing agents. Alternatively, the active agentsand other ingredients may be in powder form, obtained by asepticisolation of sterile solid or by lyophilization from solution, forconstitution with a suitable vehicle, e.g., sterile, pyrogen-free water,before use.

These formulations can contain pharmaceutically acceptable carriers,vehicles and adjuvants that are well known in the art. It is possible,for example, to prepare solutions using one or more organic solvent(s)that is/are acceptable from the physiological standpoint, chosen, inaddition to water, from solvents such as acetone, ethanol, isopropylalcohol, glycol ethers such as the products sold under the name“Dowanol,” polyglycols and polyethylene glycols, C₁-C₄ alkyl esters ofshort-chain acids, ethyl or isopropyl lactate, fatty acid triglyceridessuch as the products marketed under the name “Miglyol,” isopropylmyristate, animal, mineral and vegetable oils and polysiloxanes.

It is possible to add, if necessary, an adjuvant chosen fromantioxidants, surfactants, other preservatives, film-forming,keratolytic or comedolytic agents, perfumes, flavorings and colorings.Antioxidants such as t-butylhydroquinone, butylated hydroxyanisole,butylated hydroxytoluene and α-tocopherol and its derivatives can beadded.

Also contemplated are combination products that include one or moreagents of the present invention and one or more other therapeuticagents.

Additionally, the agents are well suited to formulation as sustainedrelease dosage forms and the like. The formulations can be soconstituted that they release the active agent, possibly over a periodof time. Coatings, envelopes, and protective matrices may be made, forexample, from polymeric substances, such as polylactide-glycolates,liposomes, microemulsions, microparticles, nanoparticles, or waxes.These coatings, envelopes, and protective matrices are useful to coatindwelling devices, e.g., stents, catheters, peritoneal dialysis tubing,draining devices and the like.

For topical administration, the therapeutic agents may be formulated asis known in the art for direct application to a target area, e.g.,chest. Forms chiefly conditioned for topical application take the form,for example, of creams, milks, gels, dispersion or microemulsions,lotions thickened to a greater or lesser extent, impregnated pads,ointments or sticks, aerosol formulations (e.g., sprays or foams),soaps, detergents, lotions or cakes of soap. Other conventional formsfor this purpose include wound dressings, coated bandages or otherpolymer coverings, ointments, creams, lotions, pastes, jellies, sprays,and aerosols. Thus, the therapeutic agents of the invention can bedelivered via patches or bandages for dermal administration.Alternatively, the agent can be formulated to be part of an adhesivepolymer, such as polyacrylate or acrylate/vinyl acetate copolymer. Forlong-term applications it might be desirable to use microporous and/orbreathable backing laminates, so hydration or maceration of the skin canbe minimized. The backing layer can be any appropriate thickness thatwill provide the desired protective and support functions. A suitablethickness will generally be from about 10 to about 200 microns.

As described above, the therapeutic agents of the invention can bedelivered via patches for transdermal administration. See U.S. Pat. No.5,560,922 for examples of patches suitable for transdermal delivery of atherapeutic agent. Patches for transdermal delivery can comprise abacking layer and a polymer matrix which has dispersed or dissolvedtherein a therapeutic agent, along with one or more skin permeationenhancers. The backing layer can be made of any suitable material whichis impermeable to the therapeutic agent. The backing layer serves as aprotective cover for the matrix layer and provides also a supportfunction. The backing can be formed so that it is essentially the samesize layer as the polymer matrix or it can be of larger dimension sothat it can extend beyond the side of the polymer matrix or overlay theside or sides of the polymer matrix and then can extend outwardly in amanner that the surface of the extension of the backing layer can be thebase for an adhesive means. Alternatively, the polymer matrix cancontain, or be formulated of, an adhesive polymer, such as polyacrylateor acrylate/vinyl acetate copolymer. For long-term applications it mightbe desirable to use microporous and/or breathable backing laminates, sohydration or maceration of the skin can be minimized.

Examples of materials suitable for making the backing layer are films ofhigh and low density polyethylene, polypropylene, polyurethane,polyvinylchloride, polyesters such as poly(ethylene phthalate), metalfoils, metal foil laminates of such suitable polymer films, and thelike. Preferably, the materials used for the backing layer are laminatesof such polymer films with a metal foil such as aluminum foil. In suchlaminates, a polymer film of the laminate will usually be in contactwith the adhesive polymer matrix.

The backing layer can be any appropriate thickness which will providethe desired protective and support functions. A suitable thickness willbe from about 10 to about 200 microns.

Generally, those polymers used to form the biologically acceptableadhesive polymer layer are those capable of forming shaped bodies, thinwalls or coatings through which therapeutic agents can pass at acontrolled rate. Suitable polymers are biologically and pharmaceuticallycompatible, nonallergenic and insoluble in and compatible with bodyfluids or tissues with which the device is contacted. The use of solublepolymers is to be avoided since dissolution or erosion of the matrix byskin moisture would affect the release rate of the therapeutic agents aswell as the capability of the dosage unit to remain in place forconvenience of removal.

Exemplary materials for fabricating the adhesive polymer layer includepolyethylene, polypropylene, polyurethane, ethylene/propylenecopolymers, ethylene/ethylacrylate copolymers, ethylene/vinyl acetatecopolymers, silicone elastomers, especially the medical-gradepolydimethylsiloxanes, neoprene rubber, polyisobutylene, polyacrylates,chlorinated polyethylene, polyvinyl chloride, vinyl chloride-vinylacetate copolymer, crosslinked polymethacrylate polymers (hydrogel),polyvinylidene chloride, poly(ethylene terephthalate), butyl rubber,epichlorohydrin rubbers, ethylenvinyl alcohol copolymers,ethylene-vinyloxyethanol copolymers; silicone copolymers, for example,polysiloxane-polycarbonate copolymers, polysiloxane-polyethylene oxidecopolymers, polysiloxane-polymethacrylate copolymers,polysiloxane-alkylene copolymers (e.g., polysiloxane-ethylenecopolymers), polysiloxane-alkylenesilane copolymers (e.g.,polysiloxane-ethylenesilane copolymers), and the like; cellulosepolymers, for example methyl or ethyl cellulose, hydroxy propyl methylcellulose, and cellulose esters; polycarbonates;polytetrafluoroethylene; and the like.

Preferably, a biologically acceptable adhesive polymer matrix should beselected from polymers with glass transition temperatures below roomtemperature. The polymer may, but need not necessarily, have a degree ofcrystallinity at room temperature. Cross-linking monomeric units orsites can be incorporated into such polymers. For example, cross-linkingmonomers can be incorporated into polyacrylate polymers, which providesites for cross-linking the matrix after dispersing the therapeuticagent into the polymer. Known cross-linking monomers for polyacrylatepolymers include polymethacrylic esters of polyols such as butylenediacrylate and dimethacrylate, trimethylol propane trimethacrylate andthe like. Other monomers which provide such sites include allylacrylate, allyl methacrylate, diallyl maleate and the like.

Preferably, a plasticizer and/or humectant is dispersed within theadhesive polymer matrix. Water-soluble polyols are generally suitablefor this purpose. Incorporation of a humectant in the formulation allowsthe dosage unit to absorb moisture on the surface of skin which in turnhelps to reduce skin irritation and to prevent the adhesive polymerlayer of the delivery system from failing.

Therapeutic agents released from a transdermal delivery system must becapable of penetrating each layer of skin. In order to increase the rateof permeation of a therapeutic agent, a transdermal drug delivery systemmust be able in particular to increase the permeability of the outermostlayer of skin, the stratum corneum, which provides the most resistanceto the penetration of molecules. The fabrication of patches fortransdermal delivery of therapeutic agents is well known to the art.

The therapeutic agent may further be formulated for topicaladministration in the mouth or throat. For example, the activeingredients may be formulated as a lozenge further comprising a flavoredbase, usually sucrose and acacia or tragacanth; pastilles comprising thecomposition in an inert base such as gelatin and glycerin or sucrose andacacia; and mouthwashes comprising the composition of the presentinvention in a suitable liquid carrier.

Ointments and creams may, for example, be formulated with an aqueous oroily base with the addition of suitable thickening and/or gellingagents. Lotions may be formulated with an aqueous or oily base and willin general also contain one or more emulsifying agents, stabilizingagents, dispersing agents, suspending agents, thickening agents, orcoloring agents. The active agents can also be delivered viaiontophoresis, e.g., as disclosed in U.S. Pat. Nos. 4,140,122;4,383,529; or 4,051,842. The percent by weight of a therapeutic agent ofthe invention present in a topical formulation will depend on variousfactors, but generally will be from 0.01% to 95% of the total weight ofthe formulation, and typically 0.1-85% by weight.

Drops, such as eye drops or nose drops, may be formulated with one ormore of the therapeutic agents in an aqueous or non-aqueous base alsocomprising one or more dispersing agents, solubilizing agents orsuspending agents. Liquid sprays are conveniently delivered frompressurized packs. Drops can be delivered via a simple eyedropper-capped bottle, or via a plastic bottle adapted to deliver liquidcontents dropwise, via a specially shaped closure.

The pharmaceutical formulations of the present invention may include, asoptional ingredients, pharmaceutically acceptable carriers, diluents,solubilizing or emulsifying agents, and salts of the type that areavailable in the art. Examples of such substances include normal salinesolutions such as physiologically buffered saline solutions and water.Specific non-limiting examples of the carriers and/or diluents that areuseful in the pharmaceutical formulations of the present inventioninclude water and physiologically acceptable buffered saline solutionssuch as phosphate buffered saline solutions pH 7.0-8.0.

The agents of the invention can also be administered to the respiratorytract. Thus, the present invention also provides aerosol pharmaceuticalformulations and dosage forms for use in the methods of the invention.Alternatively, for administration by inhalation or insufflation, thecomposition may take the form of a dry powder, for example, a powder mixof the therapeutic agent and a suitable powder base such as lactose orstarch. The powder composition may be presented in unit dosage form in,for example, capsules or cartridges, or, e.g., gelatine or blister packsfrom which the powder may be administered with the aid of an inhalator,insufflator, or a metered-dose inhaler (see, for example, thepressurized metered dose inhaler (MDI) and the dry powder inhalerdisclosed in Newinan (1984). Aromatic oils may also be administered.

Therapeutic agents of the present invention can also be administered inan aqueous solution when administered in an aerosol or inhaled form.Thus, other aerosol pharmaceutical formulations may comprise, forexample, a physiologically acceptable buffered saline solutioncontaining between about 0.1 mg/ml and about 100 mg/ml of one or more ofthe agents of the present invention specific for the indication orcondition to be treated. Dry aerosol in the form of finely divided solidparticles that are not dissolved or suspended in a liquid are alsouseful in the practice of the present invention. Agents of the presentinvention may be formulated as dusting powders and comprise finelydivided particles having an average particle size of between about 1 and5 μm, alternatively between 2 and 3 μm. Finely divided particles may beprepared by pulverization and screen filtration using techniques wellknown in the art. The particles may be administered by inhaling apredetermined quantity of the finely divided material, which can be inthe form of a powder. It will be appreciated that the unit content ofactive ingredient or ingredients contained in an individual aerosol doseof each dosage form need not in itself constitute an effective amountfor treating the particular indication or condition since the necessaryeffective amount can be reached by administration of a plurality ofdosage units. Moreover, the effective amount may be achieved using lessthan the dose in the dosage form, either individually, or in a series ofadministrations.

For administration to the upper (nasal) or lower respiratory tract byinhalation, the therapeutic agents of the invention are convenientlydelivered from a nebulizer or a pressurized pack or other convenientmeans of delivering an aerosol spray. Pressurized packs may comprise asuitable propellant such as dichlorodifluoromethane,trichlorofluoromethane, dichlorotetrafluoroethane, carbon dioxide orother suitable gas. In the case of a pressurized aerosol, the dosageunit may be determined by providing a valve to deliver a metered amount.Nebulizers include, but are not limited to, those described in U.S. Pat.Nos. 4,624,251; 3,703,173; 3,561,444; and 4,635,627. Aerosol deliverysystems of the type disclosed herein are available from numerouscommercial sources including Fisons Corporation (Bedford, Mass.),Schering Corp. (Kenilworth, N.J.) and American Pharmoseal Co.,(Valencia, Calif.). For intra-nasal administration, the therapeuticagent may also be administered via nose drops, a liquid spray, such asvia a plastic bottle atomizer or metered-dose inhaler. Typical ofatomizers are the Mistometer (Wintrop) and the Medihaler (Riker).

Furthermore, the active ingredients may also be used in combination withother therapeutic agents, for example, pain relievers, anti-inflammatoryagents, agents that inhibit protein synthesis, e.g., antimicrobials suchas erythromycin and its derivatives, tetracycline and its derivatives,puromycin and its derivatives, lincomycin and its derivatives, andstreptomycin; complex I inhibitors such as idebenone, rotenone,p-hydroxy-mercuribenzoat, roliniastatin-2, capsaicin and amytal, complexIII inhibitors, e.g., myxothiazol, antimycin A and mucidin (strobilurinA); and agents that inhibit superoxide production, for instance,xanthine oxidase inhibitors (e.g., allopurinol), and NAD(P)H oxidaseinhibitors (e.g., apocynin and diphenyleneiodonium, antihistamines,bronchodilators and the like, whether for the conditions described orsome other condition.

The present invention further pertains to a packaged pharmaceuticalcomposition such as a kit or other container. The kit or container holdsa therapeutically effective amount of an agent of the invention andinstructions for using the pharmaceutical composition for a particularindication or condition. The pharmaceutical composition includes atleast one agent of the present invention, in an effective amount.

The invention will be further described by the following non-limitingexamples.

EXAMPLE I Materials and Methods

Langendorff Perfusion and Global Ischemia/Reperfusion.

The global ischemia protocol was adapted from that of Tsuchida et al.(1994). All procedures were approved by the Animal Care and UseCommittee at The Scripps Research Institute (TSRI). To obtain isolatedhearts, hearts were excised from an anesthetized mammal such as a rabbitand quickly cannulated onto the Langendorff perfusion apparatus. Theheart is perfused with Krebs-Ringer buffer for 15 minutes beforeischemia/reperfusion episodes. No-flow ischemia is maintained for 30minutes and reperfusion is accomplished by restoring flow for 15 minutes(unless otherwise indicated). Ischemic preconditioning can be induced bythree 5 minute cycles of no-flow ischemia and reperfusion immediatelypreceding the regular ischemia and reperfusion.

In brief, the heart was excised from the anesthetized rabbit and quicklycannulated onto the Langendorff perfusion apparatus. The heart wasperfused with Krebs-Ringer buffer for 15 minutes beforeischemia/reperfusion episodes. No-flow ischemia was maintained for 30minutes and reperfusion was accomplished by restoring flow for 15minutes (unless otherwise indicated). Ischemic preconditioning wasinduced by three 5 minute cycles of no-flow ischemia and reperfusionimmediately preceding the regular ischemia and reperfusion. The efficacyof these interventions was verified by measurement of creatine kinase(CK) release and infarct size measurement using triphenyl tetrazoliumchloride (TTC) staining (Pain et al., 2000; Downey, 2001).

Isolation of Mitochondria and Cytosol.

Upon completion of global ischemia, the heart was removed from thecannula and the ventricles were minced in 20 mL per heart of ice-coldMSE buffer (225 mmol/L, mannitol, 75 mmol/L sucrose, 1 mmol/L EGTA, 1mmol/L Na₃VO₄, and 20 mmol/L HEPES-KOH [pH 7.4]). The heart was furtherpolytron-homogenized for 5 seconds at maximal power output by a PowerGen125 (Fisher Scientific) equipped with a 10 mm diameter rotor knife. Thehomogenate was centrifuged for 10 minutes at 600 g, 4° C. The pellet wasdiscarded and the supernatant was centrifuged for 10 minutes at 10,000 gto pellet mitochondria and lysosomes. The supernatant (crude cytosol)was further centrifuged for 30 minutes at 100,000 g to obtainparticulate-free cytosol (S100). The 10,000 g pellet from the previouscentrifugation was resuspended in 10 mL of MSE buffer and centrifugedfor 10 minutes at 8000 g. This wash step was repeated once. The finalpellet was resuspended in 3 mL of MSE buffer and was further purified byhybrid Percoll/metrizamide discontinuous gradient purificationconsisting of 5 mL of 6% Percoll, 2 mL of 17% metrizamide, and 2 mL of35% metrizamide, all prepared in 0.25 mol/L sucrose and set up in 13 mLtubes (Storrie et al., 1996).

Three milliliters of the sample was overlaid on top of the gradient andcentrifuged for 20 minutes at 50,000 g, 4° C., using a Beckman SW41rotor. The mitochondrial fraction at the interface between 17% and 35%metrizamide was collected and diluted at least 10-fold with MSE buffer,followed by centrifugation for 10 minutes at 10,000 g to removemetrizamide. The pellet was resuspended in 20 mL of MSE buffer andcentrifuged again. The final pellet was resuspended in 3 mL of MSEbuffer and aliquots were stored at −80° C. Protein concentration wasdetermined using the Bradford assay, and for all experiments, equalamounts of mitochondrial protein were loaded on the gels. Cytosolconcentrations were adjusted to be equal in all conditions beforeincubating with mitochondria.

Suborganellar Fractionization of Mitochondria.

A modification of the method of Comte and Gautheron (1979) was used tofractionate mitochondria. Freshly isolated purified mitochondria werepelleted by centrifugation for 5 minutes at 10,000 g. The mitochondrialpellet was resuspended in 10 mM KH₂PO₄, pH 7.4, and incubated on ice for20 minutes for hypotonic swelling. The mitochondria were centrifuged for15 minutes at 10,000 g, 4° C. to pellet mitoplasts (inner membrane andmatrix). The supernatant, containing outer membrane (OM) andintermembrane space (IMS), was centrifuged for 30 minutes at 100,000 gto separate OM (pellet) and IMS (supernatant). The mitoplast pellet wasresuspended in 500 μl of MC buffer (300 mM sucrose, 1 mM EGTA, 1 mMNa₃VO₄, 20 mM MOPS, pH 7.4) and sonicated on ice in 5 cycles of 20second bursts and 40 second rest intervals with output setting at 8-10Watts. The sonicated mitoplast preparation was centrifuged for 10minutes at 10,000 g to remove any remaining intact mitoplasts ormitochondria, followed by centrifugation at 100,000 g for 30 minutes toseparate inner membrane (IM) and matrix (MTX).

Metabolic Inhibition of Adult Cardiomyocytes.

The isolation of adult rabbit cardiomyocytes and metabolic inhibitionwere conducted as described by Gottlieb et al. (1996). Cardiomyocyteswere disrupted by nitrogen cavitation (Gottlieb et al., 2000). Themitochondria and cytosol were isolated as above except that no gradientpurification was used (He et al., 1999).

Labeling, Purification, and Identification of MitochondrialPhosphoprotein.

For phosphorylation reactions, 100 μg of purified mitochondria wasincubated in MSE buffer supplemented with 25 mmol/L HEPES-KOH [pH 7.5],10 mmol/L magnesium acetate, 10 μmol/L ATP (cold), and 10 μCi [γ-³²P]ATPfor 30 minutes at 30° C. with or without 250 μg of cytosol. The reactionmixture was subsequently centrifuged for 5 minutes at 10,000 g. Themitochondrial pellet was resuspended in 500 μL of MC buffer and washedtwice. The mitochondrial proteins were resolved on a 12% polyacrylamidegel, transferred to nitrocellulose, and detected by autoradiography.

For protein kinase inhibition experiments, cytosols were incubated withthe inhibitors at the indicated concentrations, then mitochondria wereadded and the reaction was initiated with the addition of ATP.Serine/threonine kinase inhibitors (Calbiochem, catalog No. 539572)included bisindolylmaleimide I, 10 nmol/L; H-89, 48 μmol/L; proteinkinase G inhibitor, 86 μmol/L; ML-7, 0.3 μmol/L; KN-93, 0.37 μmol/L; andstaurosporine, 10 nmol/L. Tyrosine kinase inhibitors (Calbiochem,catalogue No. 657021) included genistein, 25 μmol/L; PP2, 5 nmol/L;AG490, 15 μmol/L; AG1296, 1 μmol/L; and AG1478, 3 nmol/L.

2D Gel Electrophoresis, Mass Spectrometry, and Phosphoamino AcidAnalysis.

Determination of Phosphoamino Acids.

To determine the phosphorylated amino acid(s) of EF-Tu_(mt), theradiolabeled protein was excised from a PVDF membrane and subjected toacid hydrolysis. The hydrolyzed mixture was subjected to 1-Delectrophoresis on a thin-layer cellulose plate (Murry et al., 1986).

To prepare p46 for identification by mass spectrometry, 14 mg ofmetrizamide-purified mitochondria were obtained from two untreatedhearts. Two aliquots of mitochondria (7 mg each) were subjected tophosphorylation as above, except one of the aliquots was phosphorylatedwith non-radioactive (‘cold’) ATP. Following the reaction, themitochondria of both reactions were subjected to suborganellarfractionation as described above to obtain the IM. IM was chosen as thesource for identification of p46 because of its small volume forsubsequent 2D gel analysis and the reasonable abundance of p46. Hot and‘cold’ IM were resuspended in buffer containing 8 M urea and 20 mMTris-HCl (pH 7.4) and resolved by 2D gel electrophoresis under identicalconditions using the Pharmacia IPGphor IEF system. Both gels wereCoomassie-blue stained and dried. The gel containing the radiolabeledsample was exposed to X-ray film to localized p46. Using positionmarkers, the autoradiogram was superimposed on the gel. Three closelyspaced radioactive spots were found to precisely overlie three Coomassieblue-stained spots. These spots were located in a relatively “clean”portion of the gel with few other spots nearby, making their recognitionstraightforward. The same three spots on the non-radioactive gel werevisually identified, confirmed by overlay of the autoradiograph, andexcised for mass spectrometry analysis.

In-gel Digest of p46.

Tryptic in-gel digest of all three spots was performed as described inDiLisa et al. (1998). Unseparated tryptic peptide mixtures were dilutedwith 50% acetonitrile-5% trifluoroacetic acid to a final volume of 15μl.

MALDI Analysis.

MALDI analysis was performed as described in DiLisa et al. (1998) usinga Voyager DE-Str MALDI-TOF instrument (Applied Biosystems, Framingham,Mass.) equipped with a nitrogen laser (337 nm), operated in adelayed-extraction (Kay et al., 1997) and reflectron mode (Ferrain,1996). Mass spectra were calibrated internally on the trypsin autolysispeptides.

Peptide Sequencing by MS/MS Analysis.

For MS/MS analysis, the crude peptide mixture obtained after in-geldigest was purified over a C₁₈ reversed-phase Zip-Tip® (Millipore;Bedford, Mass.). The purified sample was supplied into a nanosprayneedle (Protana, Odense; Denmark) and analyzed on a Q-Star quadrupoletime-of-flight instrument (Sciex, Toronto; Canada) in nanospray mode.The ion spray voltage was set to 1100V. For MS/MS experiments thecollision energy Q₀ was set to 50.

Column Chromatography Purification of EF-Tu and Detection of p46.

Mitochondria were labeled with [γ-³²P]ATP and fractionated as above toobtain the matrix fraction. The mitochondrial matrix components wereresolved by anion exchange chromatography on a 1 mL DEAE-SepharoseFast-Flow column (Pharmacia) and eluted with a stepwise salt gradient(40 to 500 mmol/L KCl, in steps of 10 mmol/L, in a buffer containing 20mmol/L Tris HCl, pH 7.4). Fractions (0.5 mL) were collected,concentrated, and buffer-exchanged to 40 mmol/L KCl in 20 mmol/L TrisHCl [pH 7.4] by use of a centrifugal filter concentrator (Ultrafree-4,Millipore). Protein fractions were resolved by 12% SDS-PAGE. Immunoblotanalysis for EF-Tu was performed as described in Woriax et al. (1997).

Infarct Size Measurement.

The measurement of infarct size was essentially identical to thatdetailed by Downey (2001) except for the method of quantitation. Afterthe TTC reaction, the heart slices were scanned into TIFF files andanalyzed with Adobe Photoshop 5.5. The images were digitally manipulatedin an identical manner to ensure equivalent outcome. The brightness andcontrast were adjusted so that in the histogram essentially only red andwhite colors remained on the spectrum, corresponding to noninfarcted andinfarcted regions, respectively. The histogram counts of red and whitewere recorded. The percent infarction was calculated as white countsdivided by the sum of red plus white counts. To examine the effect ofchloramphenicol (CAP) on infarction, 100 μg/mL CAP was included in thebuffer throughout the entire procedure: 15 minutes of stabilization, 30minutes of global ischemia, and 2 hours of reperfusion (Downey, 2001).As a control for the possible interference of CAP with TTC staining, CAPwas added to the last 15 minutes of the 2 hour reperfusion.

Sequencing of EF-Tu_(mt) from Rabbit Heart cDNA.

Rabbit heart cDNA library (Stratagene, La Jolla, Calif.) was used astemplate to PCR amplify rabbit EF-Tu cDNA. The primers were based uponthe bovine sequence, the sequence of the forward primer is:5′-agcatgtggtggtgtatgtga-3′ (SEQ ID NO: 1) and the reverse primer is:5′-tgtggaacatctcaatgcctg-3′ (SEQ ID NO:2). The PCR products thusobtained were then subcloned into PCR-2.1 vector (Q-biogene, Carlsbad,Calif.) for automated sequencing at The Scripps Research InstituteDepartment of Molecular and Experimental Medicine DNA Core Lab. TABLE 1Phosphorylation of p46 Control MI PC 1 1.46 0.95 1 1.18 0.62 1 1.61 1.171 1.69 — 1 1.13 0.93 Mean 1 1.41 0.92 SD — 0.25 0.23 N 5 5 4 P(versus —<0.01 NS control)Mitochondria from control, ischemic (MI), or preconditioned (PC) heartswere labeled with [γ-³²P]ATP, then washed and resolved by SDS-PAGE.Autoradiograms were scanned using a PhosphorImager and pixel density wascompared across lanes. In each experiment, the control was normalized toa value of 1.NS indicates not significant.Results

The phosphorylation pattern of mitochondrial proteins was analyzed inhearts subjected to global ischemia for 30 minutes followed by thereperfusion for 15 minutes and compared with control perfused hearts andthose subjected to preconditioning before ischemia and reperfusion.Because [γ-³²P]orthophosphate labeling of whole hearts was impractical,mitochondria were prepared from hearts and incubated with [γ-³²P]ATP.Phosphorylation of a number of mitochondrial proteins was observed, butmitochondria from ischemic hearts consistently demonstrated greaterphosphorylation (1.4-fold, P<0.01) of a single protein of 46 kDa (seeTable 1). The extent of phosphorylation of this protein (designated p46)from preconditioned hearts was not significantly different from controlhearts. These results indicate that phosphorylation of p46 is inverselyregulated by ischemia/reperfusion and preconditioning.

To determine if phosphorylation of p46 was regulated by cytosolicfactors, cytosol was prepared from isolated control perfused hearts andfrom hearts subjected to global ischemia and reperfusion. These cytosolswere then incubated with freshly isolated mitochondria from a normalrabbit heart, in the presence of [γ-³²P]ATP. Phosphorylation of p46 inthe presence of control cytosol was quite low but increased when normalmitochondria were incubated in the presence of cytosol from ischemichearts. Mitochondria incubated in the absence of any cytosol alsodemonstrated phosphorylation of p46, suggesting that a factor present innormal cytosol suppressed phosphorylation of p46 by an endogenouskinase.

To verify that this phosphorylation activity is associated withcardiomyocytes and not due to other cell types in the heart, cytosol wasprepared from isolated adult rabbit cardiomyocytes incubated in thepresence or absence of metabolic inhibitors (2-deoxyglucose and KCN) (Heet al., 1999). Cytosol from the control cardiomyocytes again suppressedthe phosphorylation of p46. However, cytosol from the metabolicallyinhibited cardiomyocytes, either during metabolic inhibition or 10minutes after recovery, was unable to inhibit the phosphorylation of the46-kDa mitochondrial protein.

Previously, it was shown that JNK immunoreactivity and kinase activitytranslocated to mitochondria after ischemia/reperfusion but not afterischemia alone (He et al., 1999). Although p46 phosphorylation could bedetected in the absence of metabolic recovery, it was unknown whetherJNK mediated phosphorylation of p46. To examine this possibility,cytosol was immunodepleted of JNK or p38 mitogen-activated proteinkinase (MAPK). Mitochondria were then incubated with immunodepletedcontrol or ischemic cytosol in the presence of [γ-³²P]ATP.Immunodepletion of JNK or p38 MAPK did not attenuate the increase inphosphorylation mediated by ischemic cytosols, indicating that neitherof these protein kinases participates in the phosphorylation.

To gain additional information about the possible signal transductionpathway involved, the mitochondria were incubated with control orischemic cytosols in the presence of a variety of kinase inhibitors andthe effect on phosphorylation of p46 in the mitochondria assessed. Apanel of serine/threonine kinase inhibitors was tested, which includedthe broad-spectrum inhibitor staurosporine, and inhibitors of proteinkinase C (PKC), PKA, Ca²⁺/calmodulin (CaM) kinase II, myosin light chainkinase, and PKG. Mitochondria are recognized to have an associatedprotein kinase A that is anchored to the membrane by an A-kinaseanchoring protein (AKAP). However, H-89, a PKA inhibitor, did not affectphosphorylation of p46 (data not shown), suggesting that PKA was notinvolved. None of the inhibitors in the serine/threonine kinase panelsuppressed phosphorylation of p46. Tyrosine kinase inhibitors were thentested, including genistein, a broad-range inhibitor effective againstEGFR and src; PP2, an inhibitor of p56 (lck), p59 (fynI), and Hck; andAG490, an inhibitor of JAK2. The only inhibitor that reducedphosphorylation was genistein (n=3). To distinguish between a tyrosinekinase in cytosol and one endogenous to the mitochondria, we incubatedmitochondria from an ischemic heart with genistein and found that againgenistein was able to inhibit the phosphorylation of p46.

To identify p46, the inner-membrane proteins of control and ischemiccytosol-treated mitochondria were analyzed by 2D SDS-PAGE gels underidentical conditions. The isoelectric point (pI) of p46 appeared to beabout 6.5. In a preparative 2D gel for mass spectrometry analysis, threeclosely spaced Coomassie-stained spots on the 2D gel of inner-membraneproteins corresponding to radiolabeled p46 on the autoradiograph wereselected for analysis by MALDI mass spectrometry.

The obtained MALDI spectra from the three spots of interest revealedthat all three spots represented the same protein. A total of 12 massfingerprints were obtained and were subjected to a database search, butno protein could be successfully matched. Therefore, the sample obtainedfrom the middle gel spot was further analyzed by nanoelectrospray massspectrometry (MS). All peptide mass fingerprints that were observed byMALDI analysis were also found in the nanoelectrospray MS spectrum. Allpeptides were observed as double-charged ions were analyzed in separateMS/MS experiments. Not all peptides fragmented in a way that a completeion series could be obtained. Four of the analyzed peptides fragmentedwell enough to allow complete or partial sequencing. One peptideconsisting of 12 amino acids was sequenced completely, yieldingAEAGDNI(L)GAI(L)VR (SEQ ID NO:7) (“L” in parenthesis represents thepossible alternative, because MS/MS is not able to distinguish residuesI and L). The sequence I(L)I(L)DAVTYIPV (SEQ ID NO:8) was obtained froma second peptide of 13 amino acids, which was sequenced except for thelast three residues. Two more peptides were partially sequenced yielding6 and 4 amino acids, which are, respectively, EEI(L)DNA (SEQ ID NO:9)and YVSE (SEQ ID NO:10).

The two longer-sequenced peptides were subjected to a BLAST search andwere fully matched (100%) with the human and the bovine mitochondrialprecursor of the elongation factor Tu (SwissProt accession numbersP49411 and P49410, respectively). Although the rabbit sequence is not inthe database, the EF-Tu sequence is highly conserved between human andbovine (>94% identity). A partial cDNA sequence for rabbit EF-Tu_(mt)was obtained by PCR using primers corresponding to the bovine sequencefor EF-Tumt were used for PCR synthesis using rabbit heart cDNA astemplate and a partial sequence was obtained (data not shown). For thepartial sequence obtained, rabbit shares 92% homology with the humansequence and 95% homology with bovine at the amino acid level. Onepeptide sequence obtained by mass spectrometry fell within the partialcDNA sequence and matched exactly.

To verify that the phosphoprotein was indeed EF-Tu_(mt), immunoblotanalysis of a sample of radiolabeled mitochondrial protein wasconducted. Antibody to EF-Tu_(mt) (Woriax et al., 1997) recognized aseries of spots that corresponded to the phosphoprotein. To furtherconfirm that the phosphoprotein represented EF-Tu_(mt), mitochondrialextracts were partially purified on a DEAE-Sepharose anion exchangecolumn following a protocol developed for the purification of EF-Tu_(mt)(Woriax et al., 1997). Fractions were analyzed for the presence ofEF-Tu_(mt) and for the p46 phosphoprotein. As shown in FIG. 5B, theradiolabeled phosphoprotein (top panel) eluted in exactly the samefractions as EF-Tu_(mt) (bottom panel). Because EF-Tu_(mt) andEF-Ts_(mt) elute as a complex on DEAE-Sepharose, this procedure dependson different biochemical properties than 2D gel electrophoresis (Woriaxet al., 1997). It is unlikely that another protein would copurify withEF-Tu in both schemes. Based on these studies, it was concluded that thephosphoprotein is indeed EF-Tu_(mt).

The foregoing observations indicated that EF-Tu_(mt) undergoesphosphorylation in vitro. To ascertain whether EF-Tu_(mt) wasendogenously phosphorylated, mitochondria were isolated from heart inthe presence of phosphatase inhibitors and subjected to 2D gelelectrophoresis and immunodetection of EF-Tu_(mt). The antibody againstEF-Tu_(mt) detected two or possibly three spots that differed slightlyby isoelectric point. The distribution of these multiple spots iscomparable to that seen in the in vitro phosphorylation experiments andmost likely represents the addition of acidic phosphate groups. Thepresence of three spots suggests the existence of at least twophosphorylation sites. These observations provide evidence thatEF-Tu_(mt) is phosphorylated in vivo, even in control hearts. It alsoraises the possibility that the in vitro phosphorylation that isincreased after ischemia could represent “back-phosphorylation” ofavailable unphosphorylated sites, and that in control and preconditionedhearts, EF-Tu_(mt) could actually be highly phosphorylated (therebyleaving few sites available for the incorporation of radioactivephosphate in the in vitro reaction).

Mitochondria were fractionated to determine the submitochondriallocalization of the 46 kDa phosphoprotein and to compare this to thedistribution of EF-Tu_(mt). The majority of the phosphoprotein was foundin the matrix but a portion was found associated with the innermembrane. This distribution was identical to that observed forEF-Tu_(mt). The purity of submitochondrial fractions was alsodetermined. As analyzed by Western blots, an inner membrane component,the Rieske iron-sulfur protein (FeS), was found to be essentially absentfrom matrix whereas hsp60, a matrix protein, contaminated the innermembrane fraction to some degree. The distribution of EF-Tu_(mt) wascomparable to hsp60, indicating that it is likely to reside in thematrix, or is due to reversible association with the membrane. It isinteresting to note, however, that EF-Ts_(mt), which is also detected bythe antibody, is only detected in the matrix fraction. Amino acidhydrolysis demonstrated that EF-Tu_(mt) is phosphorylated on serine.

Phosphorylation of EF-Tu in prokaryotes inhibits protein translation. Itwas possible that the same might be true for eukaryotic EF-Tu. If so,then inhibition of mitochondrial protein synthesis would be expected toreproduce the effects of EF-Tu_(mt) phosphorylation. To test thispossibility, hearts were pretreated with CAP, a potent inhibitor ofmitochondrial protein synthesis, and the effects on infarct size afterischemia and reperfusion, were examined. CAP treatment reduced theinfarct size from 64.1 (±4.1) to 43.1 (±6.4) (mean±SEM) and CK release,after global ischemia suggesting that inhibition of mitochondrialprotein synthesis may be cardioprotective. CAP administered in the last15 minutes of the 2 hour reperfusion was not protective (infarct size69.2±5.7).

CAP treatment also resulted in deceased immunodetection of themitochondrial-encoded protein cytochrome oxidase subunit I while nuclearencoded mitochondrial proteins such as VDAC, ANT, Hsp60, FeS (Rieske),and cytochrome oxidase IV remained unchanged (data not shown). CAPinfusion for as little as 15 minutes was sufficient to causenear-complete loss of the mitochondrial-encoded protein cytochromeoxidase I. This suggests that turnover of some mitochondrial-encodedproteins in the heart is extremely rapid.

Discussion

A number of protein kinases are activated during ischemia, reperfusion,or preconditioning, and at least two of these are believed totranslocate to the mitochondria. It is possible that either a smallmolecule or a cytosolic kinase could transmit a signal to themitochondria to stimulate phosphorylation of EF-Tu_(mt). In fact,cytosol from normal hearts suppressed phosphorylation of EF-Tu_(mt),whereas the absence of any cytosol, or the presence of ischemic cytosol,favors phosphorylation (see above). Because the experiments describedabove were performed in the presence of phosphatase inhibitors, thiscould represent a balance between kinases and phosphatases that aredifferentially regulated by cytosolic factors.

Because phosphorylation of EF-Tu_(mt) is increased in response toischemia, the effect of ischemic preconditioning on EF-Tu_(mt)phosphorylation was determined. To measure the activity of theendogenous mitochondrial kinase with respect to EF-Tu_(mt)phosphorylation, mitochondria were isolated from control, ischemic, andpreconditioned hearts. The purified mitochondria were incubated with[γ-³²P]ATP in the absence of cytosol. Preconditioning diminished theamount of phosphorylation seen at 15 minutes of reperfusion. Aspreviously noted, mitochondria incubated in buffer only demonstrated abasal level of phosphorylation of EF-Tu_(mt), whereas cytosol fromcontrol or preconditioned hearts suppressed phosphorylation. Cytosolfrom ischemic hearts, or mitochondria prepared from ischemic hearts,stimulated phosphorylation of EF-Tu_(mt). These observations suggestthat the cytosol of normal, metabolically active cardiomyocytes iseffective in regulating the phosphorylation of EF-TU_(mt), but that thecytosol of ischemic or metabolically inhibited cells has lost theability to regulate this phosphorylation process. An alternativeinterpretation is that there is a factor present in cytosols fromischemic hearts that stimulates phosphorylation of EF-Tu_(mt). Thealtered phosphorylation of EF-Tu_(mt) in ischemic versus controlcytosols is unlikely to be due to dilution of [γ-³²P]ATP in differentconcentrations of cytosolic ATP nor due to altered ATP transport throughthe adenine nucleotide translocator, as other phosphoprotein bandsshowed similar levels of phosphorylation under all conditions. Thisphosphorylation was increased in mitochondria from hearts subjected toischemia and 15 minutes of reperfusion, but the level decreased tobaseline if reperfusion was extended to 90 minutes. These resultsindicate that phosphorylation of EF-Tu_(mt) is regulated by ischemia andby preconditioning.

Members of the MAPK family have been implicated in ischemic injury (Heet al., 1999; Raines et al., 1999; Wang et al., 1998) and inpreconditioning (Weinbrenner et al., 1997; Maulik et al., 1998; Haq etal., 1998). However, immunodepletion of JNK and p38 did not affect thephosphorylation of EF-Tu_(mt), suggesting that this may be regulated byother kinase pathways. The finding that genistein inhibitedphosphorylation and that EF-Tu_(mt) is phosphorylated on serine suggeststhat the signal transduction pathway responsible for EF-Tu_(mt)phosphorylation involves both a tyrosine kinase and a serine/threoninekinase.

What is the significance of EF-Tu_(mt) phosphorylation? Mitochondriacontain an organelle-specific protein-synthesizing system that isessential for the synthesis of the 13 polypeptides encoded by themitochondrial genome. All of the protein products of this system arecomponents of the electron transport complexes and the F₀F₁ ATP synthaselocated in the inner membrane of mitochondria. Previous investigationshave identified alterations in the function of electron transportcomplexes I and IV, which include mitochondrial encoded subunits,whereas complex II, which only contains nuclear-encoded subunits, isunaffected.

It was surprising that the major target of phosphorylation wasEF-Tu_(mt). EF-Tu is a GTPase that serves to bind aa-tRNAs and bringthem to the ribosome. In bacteria, phosphorylation of EF-Tu on threonine382 has been shown to prevent ternary complex formation (Lippmann etal., 1993; Kraal et al., 1999). This Thr residue is highly conserved inEF-Tu and is present in the mammalian mitochondrial factors whosesequences are currently available. This residue is, therefore, likely tobe a Thr in rabbit EF-Tu_(mt). The site of serine phosphorylation inrabbit EF-Tu_(mt) remains to be determined. In addition, the number ofphosphorylation sites is undetermined. The MALDI spectra were identicalfor all three spots that differed by isoelectric points, which isconsistent with two phosphorylation sites. However, it is also possiblethat glycosylation or minor proteolysis at the N- or C-terminus couldgive rise to a spot with a shifted pI without a detectable difference inmolecular mass. EF-Tu_(mt) had not previously been reported to bephosphorylated and further studies will be required to determine theeffect of this modification on its activity in protein synthesis. Thefact that EF-Tu_(mt) phosphorylation is enhanced in ischemic heartscompared with control or preconditioned hearts leads indicates that thephosphorylation carries some physiological significance. It isattractive to speculate that EF-Tu_(mt) phosphorylation leads toinactivation of mitochondrial protein synthesis with consequent loss ofmitochondrial subunits essential for function of complexes I and IV.This may explain the cardioprotective effects of CAP treatment,particularly if complex I participates in superoxide production duringreperfusion. In addition, inhibition of mitochondrial protein synthesismay be energy-sparing, allowing the utilization of limited ATP for moreessential needs.

The abundance of EF-Tu_(mt) has been shown to increase in tumor cells(Wells et al., 1995) and nearly disappears in pacing-induced heartfailure, along with a number of other mitochondrial proteins (Heinke etal., 1998). Escherichia coli EF-Tu has also been reported to function asa chaperone (Kudlicki et al., 1997). It is possible that this activityis regulated by phosphorylation. EF-Tu_(mt) may play a role analogous tothe heat shock proteins by participating in mitochondrial proteinrefolding after ischemic injury.

EXAMPLE II Methods

Langendorff Heart Perfusions.

All procedures were approved by the Animal Care and Use Committee at TheScripps Research Institute (TSRI). Rat hearts were perfused inLangendorff mode with Krebs-Ringer buffer as in Example I. CAP (300 μM)(Calbiochem, San Diego, Calif.), gentamicin sulfate (50 mg/ml) (Sigma,St. Louis, Mo.), ketoconazole (7.5 μM), sulfaphenazole (10 to 300 μm)(Sigma, St. Louis, Mo.) or cimetidine (200 to 600 μM) was added to theperfusion buffer 20 minutes before ischemia or upon reperfusion. No-flowischemia was maintained for 30 minutes and reperfusion was accomplishedby restoring flow for 15 minutes for creatine kinase (CK) releasedetermination and dihydroethidium (DHE) staining, or 120 minutes forinfarct size determination by triphenyl tetrazolium chloride (TTC)staining. Measurement of CK activity was performed using the CK EC2.7.3.2 UV-Test kit (Sigma) as per the manufacturer's instructions. Themeasurement of infarct size after TTC staining was performed asdescribed in Example 1.

Rabbit Circumflex Occlusion.

Twelve New Zealand white rabbits (2.8 to 3.9 kg) were randomized toreceive an intravenous bolus of CAP (20 mg/kg in sterile saline) orvehicle (no drug) 30 minutes before regional ischemia. Animals weremechanically ventilated with room air via a tracheostomy, and the heartwas exposed by a median stemotomy. A suture ligature was passed aroundthe circumflex coronary artery so it could be snare-occluded andreperfused as described in Gottlieb et al. (1994). Ischemia was inducedby snare occlusion and confirmed by visual inspection. After 30 minutesof ischemia, the ligature was released and the heart was reperfused for4 hours. The heart was then rapidly excised, and the normal area ofperfusion marked by infusion of acridine orange. The heart was frozenand assessed for infarct size the following day using TTC staining.Infarct size as a percentage of the area at risk (demarcated by acridineorange staining) was determined by an observer blinded to the treatmentstatus of the hearts.

Measurement of Superoxide Production.

Superoxide generation was assessed via the conversion of dihydroethidium(DHE) to ethidium as described in Miller et al. (1998). Heart slices (1mm thick) were stained in 2 mM DHE (Molecular Probes, Eugene, Oreg.) inPBS in the dark at 37° C. for 20 minutes. Sections imaged on anultraviolet transilluminator (Fisher Scientific) with a Kodak DC120digital camera (Kodak) using Kodak Digital Science 1D software (Kodak)were saved as TIFF files and analyzed using Adobe Photoshop 5.5. Therelative fluorescence intensity reflecting superoxide production wasquantified as the ratio of fluorescent (white) pixels to the total heartarea.

Preparation of Mitochondria and Measurement of Oxygen Consumption.

Hearts were rapidly minced in ice-cold MSE buffer (in mmol/L, mannitol220, sucrose 70, EGTA 2, MOPS 5 (pH 7.4), and taurine 2 supplementedwith 0.2% fatty acid-free bovine serum albumin (BSA)). Heart tissue washomogenized in MSE with a Polytron type tissue grinder at 11,000 rpm for2.5 seconds followed by 2 quick strokes at 500 rpm with a loose fitPotter-Elvehjem tissue grinder. The homogenate was centrifuged at 500 gtwice for 5 minutes, saving the supernatant. Mitochondria were pelletedfrom the supernatant by centrifugation at 3000 g twice, and the pelletwas rinsed with MSE buffer. The supernatant was saved as crude cytosol.The final pellet was rinsed and resuspended in 50 μl Incubation Medium(in mmol/L, mannitol 220, sucrose 70, EGTA 1, MOPS 5 (pH 7.4), taurine2, MgCl₂ 10, and KH₂PO₄ 5, supplemented with 0.2% fatty acid-free BSA)(Scholte et al., 1997). Mitochondria were incubated for 15 minutes onwet ice and protein concentration was determined with BSA as a standardby a Bradford assay. All work was performed on wet ice at 0° C.

Measurement of Respiration in Mitochondria from Mouse or Rat Hearts.

Oxygen consumption was measured at 30° C. with a Clark type oxygenelectrode (Instech) in 600 μl KCl respiration buffer (in mmol/L: KCl140, EGTA 1, MOPS 10 (pH 7.4), MgCl₂ 10, and KH₂PO₄ 5, supplemented with0.2% fatty acid-free BSA) (Scholte et al., 1997; Chance et al., 1961;McKee et al., 1990). Complex II activity was measured using 200 μgmitochondria with succinate, 5 mM, as a substrate. Complex IV activitywas measured using 150 μg mitochondria with TMPD, 0.4 mM and ascorbate,1 mM, as a substrate. For each complex the ADP-stimulated respirationrate (state 3) was measured after the addition of 2 mM ADP; theADP-independent respiration rate, oligomycin-insensitive (state 4) wasmeasured after the addition of 2 μM oligomycin; and the maximalrespiration rate was measured after uncoupling the mitochondria with 2μM FCCP. Rates were calculated as nA O₂/min/mg protein after subtractingthe rate that was insensitive to the inhibitors antimycin A, 1 μM, forcomplex III, and KCN, 1 mM, for complex IV. As a measure ofmitochondrial integrity, the respiratory control ratio (RCR) state 3divided by state 4 was calculated.

Immunoblotting for Mitochondrial Proteins.

Mitochondria (50 μg) were resolved by SDS-PAGE and transferred to PVDFnylon membranes. Membranes were probed for ND3 with antibodies kindlyprovided by Dr. Akemi Matsuno-Yagi, The Scripps Research Institute, andfor cytochrome oxidase subunit I (Molecular Probes, Eugene, Oreg.).Detection was performed with ECL (Amersham, Piscataway, N.J.).Non-saturated autoradiographs were quantitated with Scion/NIH Image.

Measurement of Cytochrome P450 Activity in Heart Microsomes.

Immediately following ischemia/reperfusion in the presence or absence ofCAP (300 μM), the rat hearts were homogenized in a post-mountedrotor-stator tissue homogenizer in KCl buffer (0.15 M, pH 7.4).Microsomes were isolated from rat livers (Sprague-Dawley, male, 6-8weeks) by differential centrifugation as described by Walles andcoworkers (2001). Homogenized tissue was centrifuged at 11,000 g for 30minutes at 4° C. The supernatant was further centrifuged at 170,000 gfor 60 minutes at 4° C. The resulting pellet was resuspended in KClbuffer and centrifuged at 200,000 g for 40 minutes at 4° C. Themicrosomal fraction was then transferred into Tris-sucrose buffer (0.25M sucrose, 20 mM Tris buffer, 5 mM EDTA). Protein concentrations weredetermined by bicinchoninic acid micro assay (Pierce). Microsomalsolutions were aliquoted and stored at −80° C. until further use.

Fluorometric Cytochrome P450 Assay.

Assays were carried out in parallel at 37° C. in fluorescence detectormicrotiter plates (96 well). CYP2D2 supersomes, substrates (AMMC),product standard3-[2-(N,N-diethyl-N-methylamino)ethyl]-7-hydroxy-4-methylcoumarin(AMHC), and the NADPH generating system were obtained from BD Gentest(Woburn, Mass.). Reaction components were pre-warmed to 37° C. The assaywas initiated by addition of the NADPH-regenerating system to substrateconcentrations selected to give linear time-course profiles (AMMC, 30μM) and rat liver microsomal protein (10 mg/ml) isolated as describedabove in phosphate buffer (50 mM, pH 7.4) (final organic co-solventconcentration, 0.1% acetonitrile) in the presence or absence ofsulphaphenazole (50 μM AMMC). Reaction progression was followed bycontinuously monitoring AHMC formation (λ_(ex)=390 nm and λ_(em)=460 nm)using a SPECTRAmax™ GEMINI dual-scanning microplate spectrofluorometerfor 1 hour at 37° C. The residual absorption due to NADPH wascompensated for throughout the analysis. Each assay was performed in atleast triplicate. Reaction progress was followed for no more than 10% oftotal reaction during which time the reaction rate was linear(r²>0.985). These linear initial changes in residual fluorescenceemission were converted to concentration and hence rates of productformation by comparison to standard curves. IC50 determination for AHMCwas performed using Graphpad Prism® software (San Diego, Calif.). Forcardiac microsomes, the inhibition by chloramphenicol was calculated, asa percent, by a comparison of the initial rates of AHMC formationbetween the cardiac microsomal preparations obtained from thechloramphenicol treated and untreated groups.

Statistical Analysis.

Statistical analysis was performed between groups by ANOVA usingGraphPad InState 4.10 software (San Diego, Calif.). A p value less than0.05 was considered significant.

Results

The effects of CAP administration on CK release, coronary flow andinfarct size during reperfusion were assessed in isolated rat heartsperfused in Langendorff mode. Treatment with CAP (300 μm) before andafter global no-flow ischemia (I/R+CAP) resulted in a significantreduction in infarct size from 43.2±3.2% (SEM) (n=16) (untreated) to16.0±3.6% (n=5, p<0.005) (treated), respectively (FIG. 2A). CAPadministered prior to ischemia substantially decreased the amount of CKreleased after ischemia from 2.25 U/15 min±0.28 (SEM) (n=16) inuntreated hearts to 0.27±0.13 (n=5, p<0.01). Effects on coronary flowparalleled those for cardioprotection. Gentamicin, a structurallyunrelated antibiotic, was not cardioprotective in this model, arguingagainst a possible antimicrobial effect of CAP. Furthermore,administration of chloramphenicol immediately after ischemia alsosubstantially reduced infarct size (21.7%±2.7, n=5 versus 43.2%,p<0.01), suggesting that reperfusion injury is a major determinant oftissue damage in this model.

Given that both mitochondria and cytochrome P450 monooxygenases areknown to generate ROS under certain conditions, the mechanism ofcardioprotection by CAP may be due to the known inhibitory potential ofCAP on both mitochondrial protein synthesis as well as cytochrome P450isozymes (Kraner et al., 1994). Mitochondrial protein synthesis andactivity were determined by Western blotting, mitochondrial oxygenconsumption and blue native PAGE (data not shown), respectively, toassess the effects of chloramphenicol on mitochondrial function (FIG. 2and Table 2). The latter experiments suggested that perfusion with CAPfor 30 minutes was not sufficient to alter the levels ofmitochondrial-encoded proteins or to affect respiratory chain activity,suggesting that CAP did not have an appreciable effect on mitochondria.TABLE 2 Complex I Complex II Complex IV (n Atoms O/min/mg) (n AtomsO/min/mg) (n Atoms O/min/mg State 3 State 4 State 3 State 4 State 3State 4 −CAP 158.57 ± 32 13.74 ± 6.33 85.47 ± 22.2 21.70 ± 5.89 209.85 ±40 113.99 ± 21 +CAP 162.99 ± 31 12.09 ± 4.59 83.58 ± 14.4 23.04 ± 7.32201.09 ± 23 116.89 ± 23⁺Rat hearts were perfused with or without chloramphenicol for 30minutes, then mitochondria were isolated and oxygen consumption wasassessed.

To assess if CAP administration during I/R in the Langendorff model videsupra is inactivating cardiac activity, cardiac microsomes from pooledhearts (2 per group) were isolated immediately after reperfusion in thepresence and absence of CAP and cytochrome P450 activity measured.Cytochrome P450 activity was determined for the NADPH-dependentdemethylation reaction of the fluorescent substrate3-[2-(N,N-diethyl-N-methylamino)ethyl]-7-methoxy-4-methylcoumarin (AMMC,100 μM), a substrate for the cytochrome P450 2D in rats (and P450 2C inhumans) superfamily in rats and 2C superfamily in humans. CytochromeP450 AMMC O-demethylase activity was inhibited by 95% in the microsomeprepared from CAP-treated rat hearts.

To ascertain whether the cardioprotective effect of CAP was due to theinhibition of cytochrome P450, cimetidine, a cytochrome P450 inhibitorthat does not affect mitochondrial protein synthesis was studied in theLangendorff perfusion model. Cimetidine (200-600 μM) conferred adose-dependent reduction in infarct size (FIGS. 2A-B). Parallel to itseffects on infarct size, cimetidine also reduced CK release (FIG. 2A).Post-ischemic coronary flow was also enhanced in treated hearts. SinceCAP and cimetidine are both known to inhibit the cytochrome P450 2Csubfamily (Kraner et al., 1994; Rendic et al., 1997), the selectivecytochrome P450 2C inhibitor, sulfaphenazole, was tested. Sulfaphenazole(10 μM and 300 μM) treatment resulted in a significant reduction in CKrelease and infarct size following 2 hours reperfusion, suggesting thatthe cytochrome P450 2C family may play a significant role in reperfusioninjury.

Sulfaphenazole, while being a fairly selective inhibitor of humanCYP2C9, is not known to be an inhibitor of rodent P450 isozymes.Therefore, after observing the dose-dependent protection bysulfaphenazole against ischemia-reperfusion injury, inhibition of rodentP450 isozyme activity by sulfaphenazole was examined. The effect ofsulfaphenazole concentration on rat hepatic microsome, isozyme-mediatedmodification was investigated with the fluorogenic substrate AMMC, whichis a selective substrate for CYP2D2 in rat and CYP2D6 in humans.Sulfaphenazole was found to inhibit AMMC demethylation in rat livermicrosomes (IC₅₀ 0.5 μM) (FIG. 5A). To determine whether CYP2D2 is theAMMC demethylase that is inhibited by sulfaphenazole, the effect ofsulfaphenazole (50 μM) on AMMC demethylase activity was assessed usingCYP2D2 supersomes (microsomes isolated from baculovirus-infected insectcells that specifically express CYP2D2). Interestingly, sulfaphenazoledid not appear to significantly inhibit CYP2D2 activity, suggesting thatsulfaphenazole is inhibiting a as yet unidentified CYP AMMC demethylase(FIG. 5B).

The observed cardioprotective effect of CAP is not model-specific. Inaddition to the Langendorff model, the protective effect of CAP wasstudied in a rabbit model of circumflex coronary artery occlusion.Rabbits were administered either CAP (20 mg/kg i.v. in saline) or nodrug 30 minutes before snare-occlusion of the coronary artery for 30minutes, followed by 4 hours of reperfusion (FIG. 3A). The volume of thearea at risk did not differ between the two groups (not shown). However,similar to the Langendorff model, CAP administration significantlyreduced infarct size: 49.3% of the area at risk ±17.7 (untreated) versus18.3%±12.1 (CAP treated) (n=6, p<0.05) (FIG. 3A). Post-ischemichypotension was also diminished in the drug-treated rabbits (−34.2 mmH₂O±2.3 versus −13.3±2.2, n=6, p<0.05) (FIG. 3A).

Ischemia/reperfusion injury is known to lead to elevated production ofROS, such as superoxide anion (O₂*⁻), hydrogen peroxide (H₂O₂), singletmolecular oxygen (¹O₂*) and hydroxyl radical (HO*.). To assess to whatextent the cardioprotective effect of CAP could be attributed to areduction in the production of ROS, O₂*⁻ generation was measured inheart slices obtained after 15 minutes of reperfusion (FIG. 3B). Theoxidation of dihydroethidium (DHE) to ethidium, a quantifiable chemicalmarker of superoxide anion production, was reduced approximatelythree-fold in CAP treated hearts versus ischemia/reperfusion withoutdrug (33.6%±5.0 versus 10.5±1.6, p<0.05, n=4).

Discussion

A recent RT-PCR analysis of explanted human heart tissue revealed thepresence of CYP 1A1, 2B6/7, 2C8-19, 2D6, 2E1, and 4B1 (Thum et al.,2000) as well as cytochrome P450 with arachidonic acid epoxygneaseactivity, i.e., CYP2J2 (Wu et al., 1996). Moreover, endothelial CYP2C9,which has been reported to metabolize arachidonic acid toepoxyeicosatrienoic acids (EETs), has also been shown to be afunctionally significant source of reactive oxygen species in coronaryarteries (Fleming et al., 2001). The arachidonic acid metabolizing CYPenzymes that have been linked to prominent roles in vascular regulationare the epoxygenases of the 2 gene family (e.g. 2B, 2C8, 2C9, 2C10, 2J2in humans; 2C34 in pigs; 2C11, 2C23 and 2J4 in rats) that generate aseries of regio- and stereospecific epoxides (11,12-EET, 14,15-EET,8,9-EET, and 5,6-EET) and the ω-hydroxylases belonging to the CYP 4Afamily that form HETEs (19-HETE and 20-HETE). Notably, there are someenzymes, e.g. rat CYP 4A2 and 4A3, which are capable of hydroxylationand epoxygenation(Nguyen et al., 1999).

The finding that chloramphenicol and the structural unrelated cytochromeP450 inhibitors cimetidine and sulfaphenazole reduce both infarct sizeand CK release strongly implicate cytochrome P450 monooxygenases in theheart as being important mediators of myocardial damage after ischemiaand reperfusion. Treatment with chloramphenicol, cimetidine orsulfaphenazole was also observed to prevent the associated drop incoronary flow that accompanies ischemia, suggesting that cytochrome P450inhibition may also attenuate the no-reflow phenomenon that oftenfollows an ischemic insult. Furthermore, chloramphenicol was found to bestrongly cardioprotective even when administered at reperfusion,suggesting that reperfusion injury is a major determinant of tissuedamage in the Langendorff model. Moreover, the disparity between earlyCK release and subsequent infarct size suggests that the tissue injurycontinues to evolve during early reperfusion.

Cytochrome P450 AMMC O-demethylase activity was inhibited by 95% inmicrosomes prepared from chloramphenicol-treated rat hearts.Sulfaphenazole (10 μM and 300 μM) treatment resulted in a significantreduction in creatine kinase release and infarct size following 2 hoursof reperfusion, suggesting that the CYP2C family may play a significantrole in reperfusion injury. The finding that an AMMC demethylaseactivity present in liver and cardiac microsomes was inhibited bysulfaphenazole and chloramphenicol, respectively, suggest that thiscytochrome P450 isoform may participate in reperfusion injury.

Vascular tone is regulated by the balance between superoxide anion(vasoconstriction) and nitric oxide (•NO) (vasodilation) (Cai et al.,2000). Superoxide anion reacts with •NO to generate the highly reactiveperoxynitrite (ONOO—). Therefore, diminished O₂*⁻ production incytochrome P450-inhibited hearts would be protective, via a reduction inONOO— levels and also increase coronary artery dilatation by leading tohigher levels of •NO. In support of this notion, increased coronary flowwas also observed in hearts treated with chloramphenicol, cimetidine orsulfaphenazole. The results described herein with the selectiveinhibitor sulfaphenazole suggest that a cytochrome P450 2C9 ortholog maybe a key mediator of reperfusion injury.

In humans, cytochrome P450 2C9 is also known as endothelium-derivedhyperpolarizing factor (EDHF) synthase due to its ability to convertarachidonic acid to vasoactive eicosanoids (Fisslthaler et al., 1996).Extrapolating from evidence that members of the rat 2C cytochrome P450superfamily play a key modulatory role in reperfusion injury (Fleming etal., 2001) indicates that ROS production by human cytochrome P450 2C9may override EDHF-mediated vasodilation.

Eicosanoids can serve as intracellular second messengers for proteinkinases. Cytochrome P450 enzyme-generated eicosanoids have been shown toregulate ATP-sensitive K⁺ channels on the plasma membrane. Thepossibility therefore exists that cytochrome P450 enzyme-generatedeicosanoids could modulate the mitochondrial KATP channel. Arachidonicacid is a substrate for cytochrome P450 epoxygenases as well ascytochrome P450 omega-hydroxylases, and these products have widelydifferent physiologic effects; thus, inhibition of a subset ofcytochrome P450 enzymes may have complex consequences. Thecalcium-independent phospholipase A2 (iPLA2) liberates arachidonic acid,and inhibition of iPLA2 reduces infarct size (Williams et al., 2002).These observations suggest that the participation of cytochrome P450enzymes in the metabolism of arachidonic acid is of physiologicimportance in the myocardium.

Further, cytochrome P450 enzymes affect calcium homeostasis througheicosanoid metabolites and generation of superoxide, which can affectthe function of Ca-ATPases, the sodium/calcium exchanger, and other ionchannels (Barnes et al., 2000; Zaidi et al., 1999). The pro-apoptoticprotein Bik, which shares homology with other Bcl-2 family members onlyin the BH3 domain (BH3-only), functions at the ER to trigger cytochromec release from mitochondria (Germain et al., 2002). Therefore, it islikely that cytochrome P450 enzymes regulate apoptosis in certainsettings, particularly in the setting of oxidative stress.

The observation that chloramphenicol largely abrogated dihydroethidiumconversion suggests that one or more of the heme-containing cytochromeP450 monooxygenase enzymes are the main culprits in the generation ofsuperoxide during reperfusion of the heart. This is surprisingconsidering the relatively low abundance of cytochrome P450 enzymes inheart tissue. However, dysregulated cytochrome P450 activity could leadto mitochondrial damage and secondary production of reactive oxygenspecies from the electron transfer complexes (Davydov, 2001).

These observations support the hypothesis that cytochrome P450 enzymesin the heart play a significant role in ischemia/reperfusion injury andthat inhibition of cytochrome P450 activity has therapeutic value.Moreover, the finding that cytochrome P450 monooxygenases mediatemyocardial reperfusion injury has important implications for thetreatment of cardiovascular disease. For instance, cigarette smokingupregulates cytochrome P450 enzymes (Rendic et al., 1997) and increasesthe risk of a fatal myocardial infarction (Weiner et al., 2000), whilecholesterol lowering drugs of the statin family are, for the most part,cytochrome P450 inhibitors (Corsini et al. 1999) and reducecardiovascular risk independently of their cholesterol lowering effects(Comparato et al., 2001). In particular, the HMG-CoA reductase inhibitorfluvastatin is a specific inhibitor of cytochrome P450 2C9 (Scripture etal., 2001), suggesting that cytochrome P450 2C9 inhibition in humansmay, in part, be contributing to cardioprotection. Further, cytochromeP450 expression is sexually dimorphic (Park et al., 1999), and may be areason as to the underlying decreased cardiovascular risk in women.

In summary, the present study suggests that a variety of agents alreadyin clinical use which share the property of inhibiting cytochrome P450monooxygenases and/or inhibiting enzymes with an open heme pocket,thereby inhibiting the reduction of molecular oxygen by those enzymes,may be of critical and immediate potential for adjuvant therapies toprotect organs, including the heart, against the damage that accompaniesreperfusion, e.g., to ameliorate reperfusion injury in situations asdiverse as acute myocardial infarction, balloon angioplasty, coronarybypass surgery, organ transplantation, and cerebral stroke.

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All publications, patents, and patent documents are incorporated byreference herein, as though individually incorporated by reference. Theinvention has been described with reference to various specific andpreferred embodiments and techniques. However, it should be understoodthat many variations and modifications can be made while remainingwithin the spirit and scope of the invention.

1. A method to treat or inhibit reperfusion injury in a mammal,comprising: administering to a mammal after the onset of ischemia, aneffective amount of one or more agents selected from the groupconsisting of a H₂-receptor antagonist, a H+/K+-ATPase inhibitor, anantimicrobial, an antifungal, a tricyclic antidepressant, a serotoninreuptake inhibitor, a phenothiazine, a benzodiazepine, a calcium channelblocker, and a nonsteroidal anti-inflammatory drug, wherein the one ormore agents inhibit one or more cytochrome P450 enzymes.
 2. A method toinhibit ischemia and reperfusion injury in a mammal, comprising:administering to a mammal having or at risk of having ischemia andreperfusion injury an effective amount of one or more agents selectedfrom the group consisting of a H₂-receptor antagonist, a H+/K+-ATPaseinhibitor, an antimicrobial, an antifungal, a tricyclic antidepressant,a serotonin reuptake inhibitor, a calcium channel blocker, aphenothiazine, a benzodiazepine and a nonsteroidal anti-inflammatorydrug, wherein the one or more agents inhibit one or more cytochrome P450enzymes, and wherein the amount is effective to selectively inhibit oneor more cytochrome P450 enzymes.
 3. A method to inhibit ischemia andreperfusion injury in a mammalian donor organ, comprising: contactingthe donor organ with an effective amount one or more agents selectedfrom the group consisting of a H₂-receptor antagonist, a H+/K+-ATPaseinhibitor, an antimicrobial, an antifungal, a tricyclic antidepressant,a serotonin reuptake inhibitor, a phenothiazine, a benzodiazepine, acalcium channel blocker, and a nonsteroidal anti-inflammatory drug,wherein the one or more agents inhibit one or more cytochrome P450enzymes.
 4. The method of claim 1 wherein the reperfusion injury in themammal is subsequent to myocardial ischemia.
 5. The method of claim 2wherein the mammal is suspected of having myocardial ischemia.
 6. Themethod of claim 4 or 5 wherein the myocardial ischemia is due to acutemyocardial infarction, angioplasty, coronary artery bypass graft surgerywhich includes cardiac bypass, or cardiac transplantation.
 7. The methodof claim 1 wherein the reperfusion injury in the mammal is subsequent tocerebral ischemia, renal ischemia, tissue ischemia or intestinalischemia.
 8. The method of claim 2 wherein the mammal has or is at riskof having cerebral ischemia, renal ischemia, tissue ischemia, orintestinal ischemia.
 9. The method of claim 7 or 8 wherein the cerebralischemia is due to stroke, head trauma or drowning.
 10. The method ofclaim 7 or 8 wherein the tissue ischemia is due to sepsis, cardiacarrest, shock or drowning.
 11. A method to treat or inhibit reperfusioninjury associated with myocardial infarction or vascular interventionalprocedures, comprising: administering to a mammal in need thereof aneffective amount of one or more agents selected from the groupconsisting of a H₂-receptor antagonist, a H+/K+-ATPase inhibitor, anantimicrobial, an antifungal, a tricyclic antidepressant, a serotoninreuptake inhibitor, a phenothiazine, a benzodiazepine and a nonsteroidalanti-inflammatory drug, wherein the one or more agents inhibit one ormore cytochrome P450 enzymes.
 12. The method of claim 11 wherein theprocedure is angioplasty, coronary artery bypass graft surgery whichincludes cardiac bypass or cardiac transplantation.
 13. The method ofclaim 11 wherein the one or more agents are administered before, duringor after the procedure.
 14. The method of claim 1, 2, or 11 furthercomprising administering a thrombolytic agent.
 15. The method of claim14 wherein the thrombolytic agent is administered intravenously.
 16. Themethod of claim 14 wherein the thrombolytic agent is trypsin plasminogenactivator, streptokinase, urokinase or heparin.
 17. The method of claim1, 2, 3 or 11 wherein the agent is chloramphenicol, ketoconazole,sulfaphenazole, sulfamethoxazole, trimethoprim, clotrimazole, econazole,cimetidine, metyrapone or 7-ethoxyresorufin.
 18. The method of claim 11wherein the amount administered reduces the amount of infarcted tissueby greater than 25%.
 19. The method of claim 3 wherein the donor organis a heart, kidney or liver.
 20. The method of claim 3 wherein thecontacting is prior to organ harvesting.
 21. The method of claim 3wherein the contacting is prior to transplantation.
 22. The method ofclaim 1 or 11 wherein the amount selectively inhibits one or morecytochrome P450 enzymes.
 23. The method of claim 1 or 2 wherein themammal is an organ transplant recipient.
 24. The method of claim 11wherein the vascular interventional procedure employs a stent, lasercatheter, atherectomy catheter, angioscopy device, beta or gammaradiation catheter, rotational atherectomy device, coated stent,radioactive balloon, heatable wire, heatable balloon, biodegradablestent strut, or biodegradable sleeve.